Provider Demographics
NPI:1770845752
Name:MOELLER, JESSICA (SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MOELLER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:BENDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4651 WOODSTOCK RD
Mailing Address - Street 2:STE 208-202
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-1698
Mailing Address - Country:US
Mailing Address - Phone:770-789-2257
Mailing Address - Fax:
Practice Address - Street 1:4651 WOODSTOCK RD
Practice Address - Street 2:STE 208-202
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-1698
Practice Address - Country:US
Practice Address - Phone:770-789-2257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007806235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist