Provider Demographics
NPI:1184759003
Name:REYNOLDS, JESSICA B (MS CCC SLP)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:B
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:750 E HIGHWAY 22
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65240-1146
Mailing Address - Country:US
Mailing Address - Phone:573-682-3015
Mailing Address - Fax:573-682-3015
Practice Address - Street 1:750 E HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:MO
Practice Address - Zip Code:65240-1146
Practice Address - Country:US
Practice Address - Phone:573-682-3015
Practice Address - Fax:573-682-3015
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004020295235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO469269310Medicaid