=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174284343
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA STANARD MA, CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2022
-----------------------------------------------------
Last Update Date | 01/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1150 COLONY DR
-----------------------------------------------------
City | WESTERVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43081-3624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-891-5055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7569 SOUTHVIEW CT
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43235-1631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-541-9331
-----------------------------------------------------
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 | SP.009911
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------