Provider Demographics
NPI:1396276671
Name:REVA, JESSICA ANN (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:REVA
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ANN
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6412 FOREFRONT AVE
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-7294
Mailing Address - Country:US
Mailing Address - Phone:214-232-1426
Mailing Address - Fax:972-694-0242
Practice Address - Street 1:6412 FOREFRONT AVE
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-7294
Practice Address - Country:US
Practice Address - Phone:214-232-1426
Practice Address - Fax:972-694-0242
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-27
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103175235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist