Provider Demographics
NPI:1104644244
Name:SCOGGINS, KORTNEY LEEANN
Entity type:Individual
Prefix:
First Name:KORTNEY
Middle Name:LEEANN
Last Name:SCOGGINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 361
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-0361
Mailing Address - Country:US
Mailing Address - Phone:573-587-2520
Mailing Address - Fax:573-243-3413
Practice Address - Street 1:1502 W JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-3010
Practice Address - Country:US
Practice Address - Phone:573-587-2520
Practice Address - Fax:573-243-3413
Is Sole Proprietor?:No
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024039289235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist