MEDICARE: JESSICA EVANS CCC-SLP INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	7101000969	MI

General Provider Information

NPI Number	:	1225455975
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JESSICA EVANS CCC-SLP INC.

Provider Business Mailing Address
First Line	:	1725 BOSTON ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49506-4461
Country	:	US
Telephone Number	:	786-877-5679
Fax Number	:

Provider Business Practice Location Address
First Line	:	1725 BOSTON ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49506-4461
Country	:	US
Telephone Number	:	786-877-5679
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JESSICA EVANS
Credential	:
Telephone Number	:	786-877-5679

Provider Enumeration Date	:	03/19/2014
Last Update Date	:	03/19/2014

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Directions to “JESSICA EVANS CCC-SLP INC. ” Practice Location

Language	Start Address	Practice Location

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