Provider Demographics
NPI:1457582116
Name:SIEGALL, JORDAN LESLIE (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JORDAN
Middle Name:LESLIE
Last Name:SIEGALL
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:LESLIE
Other - Last Name:GINSBURG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PROVISIONAL SLP
Mailing Address - Street 1:1000 JOHNSON FERRY RD STE A100
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-2110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 JOHNSON FERRY RD STE A100
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-2110
Practice Address - Country:US
Practice Address - Phone:770-977-9457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ 4809235Z00000X
GASLP007362235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA545158891AMedicaid