Provider Demographics
NPI:1912985649
Name:HOOPER, MARY JO (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MARY JO
Middle Name:
Last Name:HOOPER
Suffix:
Gender:F
Credentials: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:PO BOX 12156
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92658-5053
Mailing Address - Country:US
Mailing Address - Phone:949-706-0646
Mailing Address - Fax:949-706-0646
Practice Address - Street 1:2706 HILLTOP DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-5404
Practice Address - Country:US
Practice Address - Phone:949-706-0646
Practice Address - Fax:949-706-0646
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 12164235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSP002164Medicaid