Healthcare Provider Details

I. General information

NPI: 1114557238
Provider Name (Legal Business Name): JESSICA PAIGE FAMA M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2020
Last Update Date: 03/17/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6622 GORDON RD STE L
WILMINGTON NC
28411-8415
US

IV. Provider business mailing address

29 SANDRA RD
PEABODY MA
01960-5142
US

V. Phone/Fax

Practice location:
  • Phone: 910-407-7211
  • Fax:
Mailing address:
  • Phone: 978-995-3425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP96233
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number30002039
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: