Provider Demographics
NPI:1417365248
Name:VICTOR, JODIE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:
Last Name:VICTOR
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 HIGHLAND AVE NE APT 1439
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-1472
Mailing Address - Country:US
Mailing Address - Phone:954-263-7191
Mailing Address - Fax:
Practice Address - Street 1:701 HIGHLAND AVE NE APT 1439
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1472
Practice Address - Country:US
Practice Address - Phone:954-263-7191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-24
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008450235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist