MEDICARE: JESSICA QUALLEY 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	1728	ND

General Provider Information

NPI Number	:	1881253755
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA QUALLEY SLP

Provider Business Mailing Address
First Line	:	1375 S COLUMBIA RD
Second Line	:
City	:	GRAND FORKS
State	:	ND
Zip	:	58201-4015
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1375 S COLUMBIA RD
Second Line	:
City	:	GRAND FORKS
State	:	ND
Zip	:	58201-4015
Country	:	US
Telephone Number	:	701-780-2387
Fax Number	:

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

Provider Enumeration Date	:	06/13/2019
Last Update Date	:	06/13/2019

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Directions to “ JESSICA QUALLEY SLP” Practice Location

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