Individual
JESSICA E PROVOST
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.S. CCC-SLP
Contact information
Practice address
6033 LARBOARD DR., APEX, NC 27539-4115
(919) 329-7733
Mailing address
6033 LARBOARD DR., APEX, NC 27539-4115
(919) 329-7733
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
7545
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
7412731
—
NC
Enumeration date
06/12/2007
Last updated
08/06/2009
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