MEDICARE: MS. JESSICA KAE MATTINGLY M.S., 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	2202009426	VA
2	235Z00000X	Speech-Language Pathologist	116827	TX
3	235Z00000X	Speech-Language Pathologist		KY
4	235Z00000X	Speech-Language Pathologist	4775	TN
5	235Z00000X	Speech-Language Pathologist	25142	CA
6	235Z00000X	Speech-Language Pathologist	SP-1793	NV

General Provider Information

NPI Number	:	1497010482
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JESSICA KAE MATTINGLY M.S., CCC-SLP

Provider Business Mailing Address
First Line	:	425 CLIFTON HEIGHTS DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89145-4169
Country	:	US
Telephone Number	:	615-692-4230
Fax Number	:

Provider Business Practice Location Address
First Line	:	9000 LAS VEGAS BLVD S UNIT 2035
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-6406
Country	:	US
Telephone Number	:	615-692-4230
Fax Number	:

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

Provider Enumeration Date	:	07/06/2012
Last Update Date	:	07/13/2020

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