Provider Demographics
NPI:1386911733
Name:NOORDYK, JESSIE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:NOORDYK
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:JESSIE
Other - Middle Name:
Other - Last Name:NOORDYK CAMPOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:1218 GILL ST
Mailing Address - Street 2:WATERTOWN
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-2918
Mailing Address - Country:US
Mailing Address - Phone:315-777-8053
Mailing Address - Fax:
Practice Address - Street 1:1218 GILL ST
Practice Address - Street 2:WATERTOWN
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2918
Practice Address - Country:US
Practice Address - Phone:315-777-8053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-29
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021496235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist