Provider Demographics
NPI:1902372659
Name:KODA, JEMELIE J (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JEMELIE
Middle Name:J
Last Name:KODA
Suffix:
Gender:F
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 1:2812 DEERPARK DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-1019
Mailing Address - Country:US
Mailing Address - Phone:617-233-2113
Mailing Address - Fax:
Practice Address - Street 1:1201 34TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-2416
Practice Address - Country:US
Practice Address - Phone:294-661-9232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-21
Last Update Date:2018-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26791235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist