Provider Demographics
NPI:1427763028
Name:MAHONEY, JESSICA JILL (SLP-CCC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:JILL
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 N HIGHLAND AVE NE APT 1
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-1475
Mailing Address - Country:US
Mailing Address - Phone:337-577-8758
Mailing Address - Fax:
Practice Address - Street 1:11180 CRABAPPLE RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-2404
Practice Address - Country:US
Practice Address - Phone:678-277-9275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP012372235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty