Provider Demographics
NPI:1851545842
Name:EAGLESON, JAYLA RENAE (MS CCC/SLP)
Entity Type:Individual
Prefix:
First Name:JAYLA
Middle Name:RENAE
Last Name:EAGLESON
Suffix:
Gender:F
Credentials:MS CCC/SLP
Other - Prefix:
Other - First Name:JAYLA
Other - Middle Name:RENAE
Other - Last Name:WHEELDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SPEECH LANGUAGE PATH
Mailing Address - Street 1:415 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4514
Mailing Address - Country:US
Mailing Address - Phone:701-446-1034
Mailing Address - Fax:
Practice Address - Street 1:3502 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-6228
Practice Address - Country:US
Practice Address - Phone:701-446-3934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-04
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1046235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist