Provider Demographics
NPI:1659839553
Name:KRESGE, JESSICA ERIN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ERIN
Last Name:KRESGE
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 1:1010 W RESSEGUIE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4105
Mailing Address - Country:US
Mailing Address - Phone:850-687-3333
Mailing Address - Fax:
Practice Address - Street 1:3086 W MILANO DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-7288
Practice Address - Country:US
Practice Address - Phone:208-996-0552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-10
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP.0003521235Z00000X
IDSLP-4361235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COSLP.0003521OtherCOLORADO DEPARTMENT OF REGULATORY AGENCIES