Healthcare Provider Details

I. General information

NPI: 1518285907
Provider Name (Legal Business Name): JESSICA ANNE CONNERTON M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2010
Last Update Date: 05/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 152ND AVENUE NE
REDMOND WA
98052
US

IV. Provider business mailing address

11107 RENTON ISSAQUAH RD SE
ISSAQUAH WA
98027-8696
US

V. Phone/Fax

Practice location:
  • Phone: 206-412-6037
  • Fax:
Mailing address:
  • Phone: 206-793-1568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberLL60143431
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: