Provider Demographics
NPI:1518274497
Name:STANDARD, JESSICA MARIE (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:STANDARD
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:UHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:604 GOLF CREST DRIVE
Mailing Address - Street 2:SUITE 275
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-4530
Mailing Address - Country:US
Mailing Address - Phone:678-373-9705
Mailing Address - Fax:866-384-6451
Practice Address - Street 1:3105 CREEKSIDE VILLAGE DR. SUITE 604
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144
Practice Address - Country:US
Practice Address - Phone:770-974-2424
Practice Address - Fax:866-384-6451
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-13
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007204235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist