Provider Demographics
NPI:1982092961
Name:BERRY, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4699 CHARLESTON HWY
Mailing Address - Street 2:
Mailing Address - City:ROWESVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29133-9400
Mailing Address - Country:US
Mailing Address - Phone:843-906-7105
Mailing Address - Fax:
Practice Address - Street 1:4699 CHARLESTON HWY
Practice Address - Street 2:
Practice Address - City:ROWESVILLE
Practice Address - State:SC
Practice Address - Zip Code:29133-9400
Practice Address - Country:US
Practice Address - Phone:843-906-7105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-29
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6415235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist