Provider Demographics
NPI:1760021497
Name:CROSLEY, JAKE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:CROSLEY
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 W CAMBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46725-7785
Mailing Address - Country:US
Mailing Address - Phone:260-241-8305
Mailing Address - Fax:
Practice Address - Street 1:900 PROVIDENT DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3252
Practice Address - Country:US
Practice Address - Phone:574-371-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-28
Last Update Date:2019-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22006957A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist