Provider Demographics
NPI:1992003107
Name:AGNESS, JERILYN ELISSA (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JERILYN
Middle Name:ELISSA
Last Name:AGNESS
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:PO BOX 1609
Mailing Address - Street 2:
Mailing Address - City:CHALMETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70044-1609
Mailing Address - Country:US
Mailing Address - Phone:985-805-2555
Mailing Address - Fax:985-400-5303
Practice Address - Street 1:5001 HIGHWAY 190 EAST SERVICE RD STE D6
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-4956
Practice Address - Country:US
Practice Address - Phone:985-805-2555
Practice Address - Fax:985-400-5303
Is Sole Proprietor?:No
Enumeration Date:2011-03-11
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6595235Z00000X
FLSA9847235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist