Healthcare Provider Details

I. General information

NPI: 1063952182
Provider Name (Legal Business Name): JESSICA GARRETT CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2017
Last Update Date: 04/23/2022
Certification Date: 04/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 W LAKE MEAD PKWY UNIT 100
HENDERSON NV
89015-7056
US

IV. Provider business mailing address

309 W LAKE MEAD PKWY UNIT 100
HENDERSON NV
89015-7056
US

V. Phone/Fax

Practice location:
  • Phone: 702-550-2839
  • Fax:
Mailing address:
  • Phone: 702-550-2839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberC-6057
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: