Healthcare Provider Details

I. General information

NPI: 1679053755
Provider Name (Legal Business Name): JESSICA CISLO MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 S TELEGRAPH RD
MONROE MI
48161-1611
US

IV. Provider business mailing address

407 S TELEGRAPH RD
MONROE MI
48161-1611
US

V. Phone/Fax

Practice location:
  • Phone: 734-240-1950
  • Fax:
Mailing address:
  • Phone: 734-240-1950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: