Provider Demographics
NPI:1801920574
Name:TAVARES, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:TAVARES
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 1:234 LONGHILL AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:MA
Mailing Address - Zip Code:02726-2935
Mailing Address - Country:US
Mailing Address - Phone:508-324-0612
Mailing Address - Fax:
Practice Address - Street 1:374 ROCKDALE AVE
Practice Address - Street 2:ONE POSA PLACE
Practice Address - City:DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-2511
Practice Address - Country:US
Practice Address - Phone:508-996-3391
Practice Address - Fax:508-996-3397
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6984235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist