Provider Demographics
NPI:1386097137
Name:NORDSTROM, JASON (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:NORDSTROM
Suffix:
Gender:M
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 1:1274 S HIGHBUSH AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-8265
Mailing Address - Country:US
Mailing Address - Phone:479-595-2820
Mailing Address - Fax:
Practice Address - Street 1:1274 S HIGHBUSH AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-8265
Practice Address - Country:US
Practice Address - Phone:479-595-2820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR200192235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist