Provider Demographics
NPI:1801289798
Name:J BRANCH SLP SERVICES
Entity type:Organization
Organization Name:J BRANCH SLP SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:B
Authorized Official - Last Name:BRANCH
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:229-392-2521
Mailing Address - Street 1:5809 WESTLAKE DR
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-2201
Mailing Address - Country:US
Mailing Address - Phone:229-392-2521
Mailing Address - Fax:229-386-5005
Practice Address - Street 1:5809 WESTLAKE DR
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-2201
Practice Address - Country:US
Practice Address - Phone:229-392-2521
Practice Address - Fax:229-386-5005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-17
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP001263235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003148417BMedicaid
GA003158766AMedicaid