Provider Demographics
NPI:1447944079
Name:THORNBURG, JESSICA LYNN GERARD (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN GERARD
Last Name:THORNBURG
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:GERARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:65 LILLY POND RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-7883
Mailing Address - Country:US
Mailing Address - Phone:304-906-3110
Mailing Address - Fax:
Practice Address - Street 1:65 LILLY POND RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501-7883
Practice Address - Country:US
Practice Address - Phone:304-906-3110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202010870235Z00000X
WVSLP-2364235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist