MEDICARE: JERRY DANIEL MS,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	14034815	CO
2	235Z00000X	Speech-Language Pathologist	214630	CO

General Provider Information

NPI Number	:	1306529672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRY DANIEL MS,CCC-SLP

Provider Business Mailing Address
First Line	:	2883 S CIRCLE DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-4112
Country	:	US
Telephone Number	:	719-380-6230
Fax Number	:

Provider Business Practice Location Address
First Line	:	2883 S CIRCLE DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-4112
Country	:	US
Telephone Number	:	719-380-6230
Fax Number	:

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

Provider Enumeration Date	:	08/11/2023
Last Update Date	:	08/11/2023

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