Basic Information
| Provider Information | |||||||||
| NPI: | 1386722734 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN-JAMETON | ||||||||
| FirstName: | MARSHA | ||||||||
| MiddleName: | |||||||||
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| Credential: | CCC-SLP | ||||||||
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| OtherLastName: | SULLIVAN | ||||||||
| OtherFirstName: | MARSHA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 985450 NEBRASKA MED CTR | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681985450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025598943 | ||||||||
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| Practice Location | |||||||||
| Address1: | 295 PHALEN BLVD. | ||||||||
| Address2: | |||||||||
| City: | ST. PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554853969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512543200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 11/28/2017 | ||||||||
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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 | 65 | NE | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 10025289000 | 05 | NE | MEDICAID |