Provider Demographics
NPI:1871301739
Name:JEWELL, BRANDON (CCC-SLP)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:JEWELL
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3753 WILDWOOD PATH
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-9106
Mailing Address - Country:US
Mailing Address - Phone:573-429-1303
Mailing Address - Fax:
Practice Address - Street 1:4411 N HABANA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7211
Practice Address - Country:US
Practice Address - Phone:813-872-2771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-24
Last Update Date:2024-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA23085235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist