Provider Demographics
NPI:1306318522
Name:PATTEN, JALISA (SLP)
Entity type:Individual
Prefix:
First Name:JALISA
Middle Name:
Last Name:PATTEN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 W FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:ME
Mailing Address - Zip Code:04634-3106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 UNION ST
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-1534
Practice Address - Country:US
Practice Address - Phone:207-664-5311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP2608235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist