Healthcare Provider Details

I. General information

NPI: 1710354733
Provider Name (Legal Business Name): JESSICA DETTEN M.S.,CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2015
Last Update Date: 01/10/2023
Certification Date: 01/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 E MAIN ST
SPRINGERVILLE AZ
85938-5220
US

IV. Provider business mailing address

PO BOX 668
HOLBROOK AZ
86025-0668
US

V. Phone/Fax

Practice location:
  • Phone: 928-333-6800
  • Fax:
Mailing address:
  • Phone: 928-524-2123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP12499
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: