Provider Demographics
NPI:1700217502
Name:SULLIVAN, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 S SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-5553
Mailing Address - Country:US
Mailing Address - Phone:760-353-0932
Mailing Address - Fax:
Practice Address - Street 1:435 S SUNSET DR
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-5553
Practice Address - Country:US
Practice Address - Phone:760-353-0932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 1556235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist