Provider Demographics
NPI:1588012520
Name:STEWART, JESSICA LOUISE (MACCC-SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LOUISE
Last Name:STEWART
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34049 SHAWNEE ST
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-2709
Mailing Address - Country:US
Mailing Address - Phone:734-629-8610
Mailing Address - Fax:
Practice Address - Street 1:34049 SHAWNEE ST
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-2709
Practice Address - Country:US
Practice Address - Phone:734-629-8610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101002816235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist