Basic Information
| Provider Information | |||||||||
| NPI: | 1154706604 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LATHEM | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | SLP-CCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1370 N INTERSTATE DR | ||||||||
| Address2: | STE 154 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730723377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053076668 | ||||||||
| FaxNumber: | 4057016170 | ||||||||
| Practice Location | |||||||||
| Address1: | 2615 E RANDOLPH AVE | ||||||||
| Address2: | |||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737014670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802343734 | ||||||||
| FaxNumber: | 5802342615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2015 | ||||||||
| LastUpdateDate: | 07/20/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 4442 | OK | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 200598780A | 05 | OK | MEDICAID |