Provider Demographics
NPI:1730643743
Name:EKSTROM, JESSICA LEA (MS, CF-SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEA
Last Name:EKSTROM
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LEA
Other - Last Name:EKSTROM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, CF-SLP
Mailing Address - Street 1:7402 SPRINGFIELD AVE APT 7206
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78045-2507
Mailing Address - Country:US
Mailing Address - Phone:772-979-0202
Mailing Address - Fax:
Practice Address - Street 1:7001 MCPHERSON RD
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-6410
Practice Address - Country:US
Practice Address - Phone:956-723-7001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115093235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist