MEDICARE: JESSIE NELSON WILLIS CCC-SLP

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	12148957	GA

General Provider Information

NPI Number	:	1265787485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSIE NELSON WILLIS CCC-SLP

Provider Business Mailing Address
First Line	:	3203 SUTTON PL
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-3515
Country	:	US
Telephone Number	:	478-454-8889
Fax Number	:

Provider Business Practice Location Address
First Line	:	3203 SUTTON PL
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-3515
Country	:	US
Telephone Number	:	478-454-8889
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2012
Last Update Date	:	08/13/2015

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Directions to “ JESSIE NELSON WILLIS CCC-SLP” Practice Location

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