Provider Demographics
NPI:1902190705
Name:PEREZ, JORGE LEONARDO
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:LEONARDO
Last Name:PEREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:352 E CAMELBACK RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1646
Mailing Address - Country:US
Mailing Address - Phone:602-277-5006
Mailing Address - Fax:602-277-5042
Practice Address - Street 1:352 E CAMELBACK RD
Practice Address - Street 2:SUITE 102
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1646
Practice Address - Country:US
Practice Address - Phone:602-277-5006
Practice Address - Fax:602-277-5042
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA72452355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant