MEDICARE: JESSICA LEIGH POGUE ST

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	22022005785	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1487759957	OTHER	VA	ANTHEM
2	1487759957	OTHER	VA	CHAMPUS-TRICARE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	1487759957	OTHER	VA	AETNA

General Provider Information

NPI Number	:	1649504531
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA LEIGH POGUE ST

Provider Business Mailing Address
First Line	:	2875 BARN RD
Second Line	:	SUITE 100
City	:	CHRISTIANSBURG
State	:	VA
Zip	:	24073-6389
Country	:	US
Telephone Number	:	540-639-5786
Fax Number	:	540-633-0787

Provider Business Practice Location Address
First Line	:	2875 BARN RD
Second Line	:	SUITE 100
City	:	CHRISTIANSBURG
State	:	VA
Zip	:	24073-6389
Country	:	US
Telephone Number	:	540-639-5786
Fax Number	:	540-633-0787

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

Provider Enumeration Date	:	09/24/2009
Last Update Date	:	09/24/2009

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Directions to “ JESSICA LEIGH POGUE ST” Practice Location

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