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General NPI Number Information
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NPI Number | 1225455975
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Entity Type | Organization
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Legal Business Name | JESSICA EVANS CCC-SLP INC.
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Dates
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Enumeration Date | 03/19/2014
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Last Update Date | 03/19/2014
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Provider Practice Location Address
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Address Line | 1725 BOSTON ST SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49506-4461
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Country | US
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Telephone | 786-877-5679
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Fax |
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Provider Business Mailing Address
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Address Line | 1725 BOSTON ST SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49506-4461
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Country | US
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Telephone | 786-877-5679
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JESSICA EVANS
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Credential |
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Telephone | 786-877-5679
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 7101000969
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License Number State | MI
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