Provider Demographics
NPI:1851768758
Name:OBERGOENNER, EMILY JO (MA, SLP)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:JO
Last Name:OBERGOENNER
Suffix:
Gender:F
Credentials:MA, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 W JACKSON BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-3010
Mailing Address - Country:US
Mailing Address - Phone:573-587-2520
Mailing Address - Fax:
Practice Address - Street 1:1502 W JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-3010
Practice Address - Country:US
Practice Address - Phone:573-587-2520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015029740235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist