Provider Demographics
NPI:1417441833
Name:BALLARD, JARED SCOTT (CF-SLP)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:SCOTT
Last Name:BALLARD
Suffix:
Gender:M
Credentials:CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 VILLAGE CENTER BLVD UNIT 2115
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-6718
Mailing Address - Country:US
Mailing Address - Phone:304-838-4911
Mailing Address - Fax:
Practice Address - Street 1:101 BRIGHTWATER DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579
Practice Address - Country:US
Practice Address - Phone:843-492-0543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6557235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist