Provider Demographics
NPI:1629305529
Name:TICE, JESSICA A (MA, SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:TICE
Suffix:
Gender:F
Credentials:MA, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 GUILDER LN
Mailing Address - Street 2:APT. #12
Mailing Address - City:GUILDERLAND
Mailing Address - State:NY
Mailing Address - Zip Code:12084-9309
Mailing Address - Country:US
Mailing Address - Phone:518-441-1417
Mailing Address - Fax:
Practice Address - Street 1:1 RAPP RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-4491
Practice Address - Country:US
Practice Address - Phone:518-867-3061
Practice Address - Fax:518-867-3066
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-13
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019279-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist