MEDICARE: JESSICA RAE EBERHART M.S. 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		NY

General Provider Information

NPI Number	:	1649819392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA RAE EBERHART M.S. CCC-SLP

Provider Business Mailing Address
First Line	:	115 VIRGINIA AVE
Second Line	:
City	:	LAKE GROVE
State	:	NY
Zip	:	11755-2824
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	622 HAWKINS AVE
Second Line	:
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-2374
Country	:	US
Telephone Number	:	631-240-3579
Fax Number	:

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

Provider Enumeration Date	:	12/29/2019
Last Update Date	:	12/29/2019

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Directions to “ JESSICA RAE EBERHART M.S. CCC-SLP” Practice Location

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