Healthcare Provider Details

I. General information

NPI: 1558857656
Provider Name (Legal Business Name): MIRANDA JEANMARD MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 04/16/2020
Certification Date: 04/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 MAIN ST
FAIRFAX VA
22030-6995
US

IV. Provider business mailing address

13219 WARBURTON DR
FORT WASHINGTON MD
20744-6530
US

V. Phone/Fax

Practice location:
  • Phone: 703-273-7705
  • Fax:
Mailing address:
  • Phone: 601-543-9422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202009149
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: