Provider Demographics
NPI:1356714588
Name:BOEHM, JESSICA GINN (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:GINN
Last Name:BOEHM
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 1:5214 WALTON WAY
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-3498
Mailing Address - Country:US
Mailing Address - Phone:678-499-4693
Mailing Address - Fax:
Practice Address - Street 1:5214 WALTON WAY
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-3498
Practice Address - Country:US
Practice Address - Phone:678-499-4693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-10
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP004728235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist