Provider Demographics
NPI:1821311432
Name:KO, JESSICA CANDICE (MCD, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:CANDICE
Last Name:KO
Suffix:
Gender:F
Credentials:MCD, 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:PO BOX 573
Mailing Address - Street 2:
Mailing Address - City:ASH FLAT
Mailing Address - State:AR
Mailing Address - Zip Code:72513
Mailing Address - Country:US
Mailing Address - Phone:870-219-1086
Mailing Address - Fax:
Practice Address - Street 1:148 LINWOOD DR
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-4077
Practice Address - Country:US
Practice Address - Phone:870-219-1086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-10
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR924768805235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR179755721Medicaid