Codie Jaclyn Green

Primary specialty

Speech-Language PathologistTaxonomy code 235Z00000X

License

S-4294 Issued in MS

Practice address

668 Old Salt Rd
Sumrall, MS 39482-4232

Phone

(601) 270-6968

Fax

(601) 336-5255

NPI assigned

Jun 20, 2022

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Aultman Speech Therapy Services, LLC

  • Speech-Language Pathologist
  • Sumrall, MS
  • NPI 1912154220
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1655683200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1655683200000",
    "number": "1225769482",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "17 E CHERRY",
            "city": "SUMRALL",
            "state": "MS",
            "postal_code": "394820400"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "668 OLD SALT RD",
            "city": "SUMRALL",
            "state": "MS",
            "postal_code": "394824232",
            "telephone_number": "601-270-6968",
            "fax_number": "601-336-5255"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "4805 W 4th St",
            "address_purpose": "LOCATION",
            "city": "Hattiesburg",
            "state": "MS",
            "postal_code": "394021019",
            "country_code": "US",
            "telephone_number": "601-270-6968",
            "fax_number": "601-336-5255",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "GREEN",
        "first_name": "CODIE",
        "middle_name": "JACLYN",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2022-06-20",
        "last_updated": "2022-06-20",
        "certification_date": "2022-06-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "235Z00000X",
            "taxonomy_group": "",
            "desc": "Speech-Language Pathologist",
            "state": "MS",
            "license": "S-4294",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "OTHERS",
            "endpointTypeDescription": "Other URL",
            "endpoint": "https://app.fusionwebclinic.com/portal/aultmanspeechtherapy",
            "affiliation": "N",
            "address_1": "668 Old Salt Rd",
            "city": "Sumrall",
            "state": "MS",
            "country_code": "US",
            "postal_code": "394824232",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Melody Davisson, LCSW
• Grace E Dickerson, LMFT
• Susan L Dubose, FNP-BC
• Family Drug Mart of Sumrall, LLC
• Shelby Herndon Graves, COTA
• Beau Landry Haden, PHARMD
• Tasha F Haden, PHARMD
• Hattiesburg Clinic PA
• Hattiesburg Clinic, PA
• Clouzetta D Howze

• Speech-Language Pathologist in Sumrall, MS
• Providers in Sumrall, MS by specialty
• Speech-Language Pathologist in Mississippi

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 20, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.