Provider Demographics
NPI:1932797040
Name:KHATTAB, JESSICA DAWN (CF-SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DAWN
Last Name:KHATTAB
Suffix:
Gender:F
Credentials:CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6205 WILEY DR
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29680-6495
Mailing Address - Country:US
Mailing Address - Phone:516-782-6253
Mailing Address - Fax:
Practice Address - Street 1:355 OAK GROVE RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-2537
Practice Address - Country:US
Practice Address - Phone:864-595-4225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSLP.7298SPIN235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist