Provider Demographics
NPI:1487487419
Name:CONRAD, JESSICA L
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:CONRAD
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 1:826 BOONEWAY LN
Mailing Address - Street 2:
Mailing Address - City:BARGERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46106-8465
Mailing Address - Country:US
Mailing Address - Phone:317-694-5317
Mailing Address - Fax:
Practice Address - Street 1:826 BOONEWAY LN
Practice Address - Street 2:
Practice Address - City:BARGERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46106-8465
Practice Address - Country:US
Practice Address - Phone:317-694-5317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-23
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22005401A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist