Provider Demographics
NPI:1265787485
Name:WILLIS, JESSIE NELSON (CCC-SLP)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:NELSON
Last Name:WILLIS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3203 SUTTON PL
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-3515
Mailing Address - Country:US
Mailing Address - Phone:478-454-8889
Mailing Address - Fax:
Practice Address - Street 1:3203 SUTTON PL
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-3515
Practice Address - Country:US
Practice Address - Phone:478-454-8889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-14
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12148957235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist