MEDICARE: MRS. JESSICA BANASHAK M.A.CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	LL60016404	WA

General Provider Information

NPI Number	:	1124287891
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSICA BANASHAK M.A.CCC-SLP

Provider Business Mailing Address
First Line	:	4560 SE INTERNATIONAL WAY
Second Line	:	SUITE 100
City	:	MILWAUKIE
State	:	OR
Zip	:	97222-4628
Country	:	US
Telephone Number	:	971-206-5200
Fax Number	:

Provider Business Practice Location Address
First Line	:	7125 FAUNTLEROY WAY SW
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98136-2008
Country	:	US
Telephone Number	:	206-937-2800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2008
Last Update Date	:	03/17/2011

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