Provider Demographics
NPI:1932693694
Name:WHITE, JESSICA ANN (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:WHITE
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PORTAGE WAY
Mailing Address - Street 2:
Mailing Address - City:COLONA
Mailing Address - State:IL
Mailing Address - Zip Code:61241-8642
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6210 GIBSON LN APT 4306
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-1253
Practice Address - Country:US
Practice Address - Phone:319-572-4192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-17
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR200101OtherARKANSAS BOARD OF EXAMINERS SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY LICENSE
TX113258OtherTEXAS DEPARTMENT OF LICENSING AND REGULATION
MD14110526OtherAMERICAN SPEECH-LANGUAGE-HEARING ASSOCIATION