Provider Demographics
NPI:1417350869
Name:SHANK, JAYDE SUE (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JAYDE
Middle Name:SUE
Last Name:SHANK
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:JAYDE
Other - Middle Name:SUE
Other - Last Name:GATER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-0188
Mailing Address - Country:US
Mailing Address - Phone:740-773-4366
Mailing Address - Fax:
Practice Address - Street 1:141 COLUMBUS RD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-1315
Practice Address - Country:US
Practice Address - Phone:740-589-5132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-30
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10361235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0Medicaid