Provider Demographics
NPI:1750543278
Name:PEDERSON, JESSICA ELIZABETH (MS CF/SLP)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ELIZABETH
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:MS CF/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 EL MILENO DRIVE
Mailing Address - Street 2:SUITE A-103
Mailing Address - City:PALMHURST
Mailing Address - State:TX
Mailing Address - Zip Code:78573-1223
Mailing Address - Country:US
Mailing Address - Phone:956-821-0103
Mailing Address - Fax:956-513-0696
Practice Address - Street 1:1906 EL MILENO DR
Practice Address - Street 2:
Practice Address - City:PALMHURST
Practice Address - State:TX
Practice Address - Zip Code:78573-1223
Practice Address - Country:US
Practice Address - Phone:956-821-0103
Practice Address - Fax:956-513-0696
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103864235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX196103901Medicaid