Provider Demographics
NPI:1912288366
Name:AHN, JESSICA (MA, CCC - SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:AHN
Suffix:
Gender:F
Credentials:MA, CCC - SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23919 66TH AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:DOUGLASTON
Mailing Address - State:NY
Mailing Address - Zip Code:11362-1922
Mailing Address - Country:US
Mailing Address - Phone:646-510-1464
Mailing Address - Fax:
Practice Address - Street 1:2324 FOREST AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10303-1506
Practice Address - Country:US
Practice Address - Phone:718-447-0200
Practice Address - Fax:718-981-1431
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021309-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist