Provider Demographics
NPI:1497010482
Name:MATTINGLY, JESSICA KAE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:KAE
Last Name:MATTINGLY
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 1:425 CLIFTON HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-4169
Mailing Address - Country:US
Mailing Address - Phone:615-692-4230
Mailing Address - Fax:
Practice Address - Street 1:9000 LAS VEGAS BLVD S UNIT 2035
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-6406
Practice Address - Country:US
Practice Address - Phone:615-692-4230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-06
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202009426235Z00000X
TX116827235Z00000X
KY235Z00000X
TN4775235Z00000X
CA25142235Z00000X
NVSP-1793235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist