Provider Demographics
NPI:1366519001
Name:PRUITT, JESICA C (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JESICA
Middle Name:C
Last Name:PRUITT
Suffix:
Gender:F
Credentials: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 1:9818 NE 200TH ST
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-2300
Mailing Address - Country:US
Mailing Address - Phone:425-941-3768
Mailing Address - Fax:
Practice Address - Street 1:9818 NE 200TH ST
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-2300
Practice Address - Country:US
Practice Address - Phone:425-941-3768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00004202235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA12090673OtherASHA NUMBER
WA7411852OtherAETNA PROVIDER NUMBER
WA8461469Medicaid
WA7028319Medicaid