Provider Demographics
NPI:1154934172
Name:WALLIS, JODIE (CLC, MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JODIE
Middle Name:
Last Name:WALLIS
Suffix:
Gender:F
Credentials:CLC, MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 HERITAGE LNDG STE 201
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63303-8488
Mailing Address - Country:US
Mailing Address - Phone:636-748-0170
Mailing Address - Fax:
Practice Address - Street 1:1600 HERITAGE LNDG STE 201
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63303-8488
Practice Address - Country:US
Practice Address - Phone:636-748-0170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2024-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist