Healthcare Provider Details

I. General information

NPI: 1396463469
Provider Name (Legal Business Name): JESSICA TATUM REGAN CF-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2022
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 WAKEFIELD ST
ROCHESTER NH
03867-1399
US

IV. Provider business mailing address

9 JUANITA AVE APT 2
RAYMOND NH
03077-2504
US

V. Phone/Fax

Practice location:
  • Phone: 508-826-3939
  • Fax:
Mailing address:
  • Phone: 508-826-3939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberP-0924
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: