=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609205616
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA REGINA DAVIS MS CCC/SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2013
-----------------------------------------------------
Last Update Date | 11/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2600 W RUN RD
-----------------------------------------------------
City | MUNHALL
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15120-2869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-462-8002
-----------------------------------------------------
Fax | 412-462-2113
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1229 STRATFORD DR
-----------------------------------------------------
City | ELIZABETH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15037-3110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-277-1059
-----------------------------------------------------
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 | SL008258
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------