Provider Demographics
NPI:1023658309
Name:MINER, JESSICA SUSAN (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:SUSAN
Last Name:MINER
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 1:2601 LAKESIDE PKWY APT 311
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75022-4298
Mailing Address - Country:US
Mailing Address - Phone:801-722-9803
Mailing Address - Fax:
Practice Address - Street 1:1001 CROSS TIMBERS RD STE 1240
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-8866
Practice Address - Country:US
Practice Address - Phone:972-966-1079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115880235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist