Provider Demographics
NPI:1912030156
Name:SMITH, JESSICA DANIELLE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DANIELLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS 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:RR 4 BOX 58
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-9350
Mailing Address - Country:US
Mailing Address - Phone:304-984-0046
Mailing Address - Fax:304-984-3875
Practice Address - Street 1:302 CEDAR RIDGE RD
Practice Address - Street 2:
Practice Address - City:SISSONVILLE
Practice Address - State:WV
Practice Address - Zip Code:25320-9502
Practice Address - Country:US
Practice Address - Phone:304-984-0046
Practice Address - Fax:304-984-3875
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1192235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist