Provider Demographics
NPI:1710354733
Name:DETTEN, JESSICA (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DETTEN
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 668
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:AZ
Mailing Address - Zip Code:86025-0668
Mailing Address - Country:US
Mailing Address - Phone:928-524-2123
Mailing Address - Fax:
Practice Address - Street 1:418 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGERVILLE
Practice Address - State:AZ
Practice Address - Zip Code:85938-5220
Practice Address - Country:US
Practice Address - Phone:928-333-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-25
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP12499235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
14065279OtherASHA
AZSLP12499OtherAZ DEPT OF HEALTH SERVICES
AZ6138712OtherAZ DEPT OF ED