Provider Demographics
NPI:1780992701
Name:PEDRICK, JADE GRAYCE
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:GRAYCE
Last Name:PEDRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 SPINNAKER WAY
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-3369
Mailing Address - Country:US
Mailing Address - Phone:518-669-2714
Mailing Address - Fax:
Practice Address - Street 1:8 NOBLE LN
Practice Address - Street 2:
Practice Address - City:BERWICK
Practice Address - State:ME
Practice Address - Zip Code:03901-2842
Practice Address - Country:US
Practice Address - Phone:207-698-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEST2061235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist