Provider Demographics
NPI:1154706604
Name:LATHEM, JESSICA L (SLP-CCC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:LATHEM
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 N INTERSTATE DR
Mailing Address - Street 2:STE 154
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-3377
Mailing Address - Country:US
Mailing Address - Phone:405-307-6668
Mailing Address - Fax:405-701-6170
Practice Address - Street 1:2615 E RANDOLPH AVE
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-4670
Practice Address - Country:US
Practice Address - Phone:580-234-3734
Practice Address - Fax:580-234-2615
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4442235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200598780AMedicaid