Provider Demographics
NPI:1003059148
Name:JENNINGS, MAUREEN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:F
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 1:2301 ROSCOMARE RD
Mailing Address - Street 2:#104
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1836
Mailing Address - Country:US
Mailing Address - Phone:310-663-3868
Mailing Address - Fax:
Practice Address - Street 1:2301 ROSCOMARE RD
Practice Address - Street 2:#104
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90077-1836
Practice Address - Country:US
Practice Address - Phone:310-663-3868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-17
Last Update Date:2013-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017067235Z00000X
CA15568235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist