Provider Demographics
NPI:1114557238
Name:FAMA, JESSICA PAIGE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:PAIGE
Last Name:FAMA
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 SANDRA RD
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-5142
Mailing Address - Country:US
Mailing Address - Phone:978-995-3425
Mailing Address - Fax:
Practice Address - Street 1:6622 GORDON RD STE L
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411-8415
Practice Address - Country:US
Practice Address - Phone:910-407-7211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-16
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MASLP96233235Z00000X
NC30002039235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMTN60246151OtherBLUE CROSS BLUE SHIELD