Provider Demographics
NPI:1114658382
Name:ELLISON, JESSICA J (SLP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:J
Last Name:ELLISON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:3006 ROBIN TERRY CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-2475
Mailing Address - Country:US
Mailing Address - Phone:843-291-5995
Mailing Address - Fax:
Practice Address - Street 1:3006 ROBIN TERRY CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-2475
Practice Address - Country:US
Practice Address - Phone:843-291-5995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2024-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30002889235Z00000X
OHSP.15173235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist