Provider Demographics
NPI:1710491659
Name:JESKE, OLIVIA TESS (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:TESS
Last Name:JESKE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:TESS
Other - Last Name:DONDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MAIDEN
Mailing Address - Street 1:1133 N H ST STE I
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-8137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1133 N H ST STE I
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-8137
Practice Address - Country:US
Practice Address - Phone:805-733-4542
Practice Address - Fax:805-733-4392
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP25948235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSP00390Medicaid