Provider Demographics
NPI:1912517244
Name:JO, KAILEY NICOLE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KAILEY
Middle Name:NICOLE
Last Name:JO
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 1:5940 MILL POINT CT SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-9363
Mailing Address - Country:US
Mailing Address - Phone:616-307-3512
Mailing Address - Fax:
Practice Address - Street 1:710 KENMOOR AVE SE STE 110
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2379
Practice Address - Country:US
Practice Address - Phone:616-591-2905
Practice Address - Fax:616-333-2321
Is Sole Proprietor?:No
Enumeration Date:2020-08-02
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101006090235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist