Healthcare Provider Details

I. General information

NPI: 1922369909
Provider Name (Legal Business Name): JESSICA PANGBORN MS CCC SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 06/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2011 CORONA RD STE 301
COLUMBIA MO
65203-2548
US

IV. Provider business mailing address

15444 S GREENWOOD ST
OLATHE KS
66062-3460
US

V. Phone/Fax

Practice location:
  • Phone: 314-543-3860
  • Fax:
Mailing address:
  • Phone: 414-405-4403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2011013608
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: