Provider Demographics
NPI:1770096265
Name:LARSON, JESSICA LEE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:LARSON
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 1:9160 KRISTI CT NW
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311-9010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4183 SUNNYSLOPE RD SW
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98367-7677
Practice Address - Country:US
Practice Address - Phone:360-443-3503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60779490235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
14074866OtherAMERICAN SPEECH-LANGUAGE-HEARING ASSOCIATION (ASHA)