Provider Demographics
NPI:1780029017
Name:COYLE, JESSE GABRIEL (CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:GABRIEL
Last Name:COYLE
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 1:2855 PINECREEK DR
Mailing Address - Street 2:F 401
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5400
Mailing Address - Country:US
Mailing Address - Phone:714-580-4888
Mailing Address - Fax:
Practice Address - Street 1:2855 PINECREEK DR
Practice Address - Street 2:F 401
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5400
Practice Address - Country:US
Practice Address - Phone:714-580-4888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20397235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist