Provider Demographics
NPI:1699340174
Name:JAZDZYK, TESSA (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:TESSA
Middle Name:
Last Name:JAZDZYK
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11253 PATTERSON RD
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:MI
Mailing Address - Zip Code:49451-9560
Mailing Address - Country:US
Mailing Address - Phone:231-740-7540
Mailing Address - Fax:
Practice Address - Street 1:4650 HOEN AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-9407
Practice Address - Country:US
Practice Address - Phone:707-546-0471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14360811235Z00000X
CA14360811235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist