Provider Demographics
NPI:1770899106
Name:DERBY, JESSIE LYNN (MS SLP)
Entity type:Individual
Prefix:MRS
First Name:JESSIE
Middle Name:LYNN
Last Name:DERBY
Suffix:
Gender:F
Credentials:MS SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 123
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:NE
Mailing Address - Zip Code:68058-0123
Mailing Address - Country:US
Mailing Address - Phone:402-679-2338
Mailing Address - Fax:
Practice Address - Street 1:7 ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-0239
Practice Address - Country:US
Practice Address - Phone:712-328-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-23
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE259235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist