=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134475916
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOURDAN TAYLOR SALAS M.A., CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2012
-----------------------------------------------------
Last Update Date | 01/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5825 GLENRIDGE DR STE 133
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-733-9318
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5825 GLENRIDGE DR STE 133
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30328-5387
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-733-9318
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 4481
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 8143
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------