Provider Demographics
NPI:1770027484
Name:BAXTER, JENESSA LYNN (SLP-3375)
Entity Type:Individual
Prefix:
First Name:JENESSA
Middle Name:LYNN
Last Name:BAXTER
Suffix:
Gender:F
Credentials:SLP-3375
Other - Prefix:
Other - First Name:JENESSA
Other - Middle Name:LYNN
Other - Last Name:BURROUGHS, HARRISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14526 W COMISKY DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-0966
Mailing Address - Country:US
Mailing Address - Phone:208-880-1554
Mailing Address - Fax:
Practice Address - Street 1:14526 W COMISKY DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0966
Practice Address - Country:US
Practice Address - Phone:208-880-1554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-14
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-3375235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist