Provider Demographics
NPI:1629129085
Name:JARVIS, MARY L (MACCCSLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:L
Last Name:JARVIS
Suffix:
Gender:F
Credentials:MACCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19243 EAGLETOWN RD
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-9228
Mailing Address - Country:US
Mailing Address - Phone:317-867-2191
Mailing Address - Fax:317-867-2191
Practice Address - Street 1:19243 EAGLETOWN RD
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-9228
Practice Address - Country:US
Practice Address - Phone:317-867-2191
Practice Address - Fax:317-867-2191
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22002405A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist