Healthcare Provider Details

I. General information

NPI: 1205764883
Provider Name (Legal Business Name): JEAN CHAMPION MA, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 KALMUS DR
COSTA MESA CA
92626-5922
US

IV. Provider business mailing address

200 KALMUS DR
COSTA MESA CA
92626-5922
US

V. Phone/Fax

Practice location:
  • Phone: 714-966-4000
  • Fax:
Mailing address:
  • Phone: 714-966-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22173
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: