Provider Demographics
NPI:1245539063
Name:POWELL, JAY (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:POWELL
Suffix:
Gender:M
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 1:800 GARFIELD AVENUE
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101
Mailing Address - Country:US
Mailing Address - Phone:304-424-2111
Mailing Address - Fax:304-424-2720
Practice Address - Street 1:800 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-5340
Practice Address - Country:US
Practice Address - Phone:304-424-2111
Practice Address - Fax:304-424-2720
Is Sole Proprietor?:No
Enumeration Date:2011-03-18
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-O675235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist