Basic Information
| Provider Information | |||||||||
| NPI: | 1346857562 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FETGATTER | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | ALYSSA | ||||||||
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| Credential: | MS, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2814 PARKSIDE VILLAGE LN | ||||||||
| Address2: | |||||||||
| City: | PEARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775817258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135530265 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10800 FLORA MAE MEADOWS RD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770895974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8323282350 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2020 | ||||||||
| LastUpdateDate: | 09/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 114716 | TX | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.