Provider Demographics
NPI:1386860120
Name:FESUK, JAIME GAYLE
Entity Type:Individual
Prefix:MRS
First Name:JAIME
Middle Name:GAYLE
Last Name:FESUK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1998 PRESCOTT LAKES PARKWAY
Mailing Address - Street 2:#141
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-7825
Mailing Address - Country:US
Mailing Address - Phone:928-830-0052
Mailing Address - Fax:
Practice Address - Street 1:146 S GRANITE ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-4710
Practice Address - Country:US
Practice Address - Phone:928-445-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPL4197235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist