Provider Demographics
NPI:1285221408
Name:MARSHALL, KRISTIAN JERNE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:KRISTIAN
Middle Name:JERNE
Last Name:MARSHALL
Suffix:
Gender:
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 BAYOU OAKS DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-3337
Mailing Address - Country:US
Mailing Address - Phone:318-789-8931
Mailing Address - Fax:
Practice Address - Street 1:130 BAYOU OAKS DR APT 617
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-3347
Practice Address - Country:US
Practice Address - Phone:318-789-8931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
LA3016089235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3016089Medicaid
LA8760OtherLOUISIANA SPEECH PATHOLOGY LICENSE