Healthcare Provider Details

I. General information

NPI: 1326530874
Provider Name (Legal Business Name): JESSICA LYNN CASSIDY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12110 CLAYTON RD
SAINT LOUIS MO
63131-2516
US

IV. Provider business mailing address

5429 MURDOCH AVE
SAINT LOUIS MO
63109-2844
US

V. Phone/Fax

Practice location:
  • Phone: 314-989-8100
  • Fax:
Mailing address:
  • Phone: 573-776-3186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2018016948
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: