Basic Information
| Provider Information | |||||||||
| NPI: | 1992003107 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AGNESS | ||||||||
| FirstName: | JERILYN | ||||||||
| MiddleName: | ELISSA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1609 | ||||||||
| Address2: | |||||||||
| City: | CHALMETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700441609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858052555 | ||||||||
| FaxNumber: | 9854005303 | ||||||||
| Practice Location | |||||||||
| Address1: | 5001 HIGHWAY 190 EAST SERVICE RD STE D6 | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704334956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858052555 | ||||||||
| FaxNumber: | 9854005303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2011 | ||||||||
| LastUpdateDate: | 03/22/2018 | ||||||||
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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 | 6595 | LA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | SA9847 | FL | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.