Healthcare Provider Details

I. General information

NPI: 1245976190
Provider Name (Legal Business Name): JESSICA S CORNISH SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2022
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 LONG BEACH BLVD STE 700
LONG BEACH CA
90807-2000
US

IV. Provider business mailing address

10 TOP FLIGHT CT
IRMO SC
29063-7963
US

V. Phone/Fax

Practice location:
  • Phone: 818-894-2273
  • Fax: 818-357-2505
Mailing address:
  • Phone: 803-760-0940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP-6335
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP15524
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSAH-2024-0232
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number8015
License Number StateSC
# 5
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number37244
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: