Provider Demographics
NPI:1437239332
Name:WYMORE, JESSIE LEE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JESSIE
Middle Name:LEE
Last Name:WYMORE
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 1:4601 HARTFORD ST.
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79605-1731
Mailing Address - Country:US
Mailing Address - Phone:325-793-3411
Mailing Address - Fax:
Practice Address - Street 1:3001 SOUTH JACKSON
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904
Practice Address - Country:US
Practice Address - Phone:325-793-3411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105610235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS115824OtherBCBS