Provider Demographics
NPI:1407064520
Name:FUSSELL, JESSICA I (MCD)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:I
Last Name:FUSSELL
Suffix:
Gender:F
Credentials:MCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81337 OK LN
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70435-8272
Mailing Address - Country:US
Mailing Address - Phone:985-705-6784
Mailing Address - Fax:
Practice Address - Street 1:81337 OK LN
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70435-8272
Practice Address - Country:US
Practice Address - Phone:985-705-6784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
LA5626235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1714313Medicaid