Provider Demographics
NPI:1184263774
Name:AHNMARK, JESSIE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:AHNMARK
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 1:636 LOWER TOM BURKE RD
Mailing Address - Street 2:
Mailing Address - City:GALLATIN GATEWAY
Mailing Address - State:MT
Mailing Address - Zip Code:59730-8576
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:636 LOWER TOM BURKE RD
Practice Address - Street 2:
Practice Address - City:GALLATIN GATEWAY
Practice Address - State:MT
Practice Address - Zip Code:59730-8576
Practice Address - Country:US
Practice Address - Phone:530-864-4867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-30
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTSLP-SP-LIC-8489235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty