Healthcare Provider Details

I. General information

NPI: 1538204284
Provider Name (Legal Business Name): WYLANTA RENE JONES SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: WYLANTA RENE ROBERTS

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HUMBOLDT UNIFIED SCHOOL DISTRICT #22 SPECIAL SRVCS OFIC 8766 EAST HWY 69
PRESCOTT VALLEY AZ
86314
US

IV. Provider business mailing address

14050 S HWY 69
MAYER AZ
86333
US

V. Phone/Fax

Practice location:
  • Phone: 928-759-4028
  • Fax: 928-759-4030
Mailing address:
  • Phone: 623-326-2150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP2190
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: