Provider Demographics
NPI:1053512079
Name:COLOMBO, JENNIFER E (CCC SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:COLOMBO
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 1:6977 PROFESSIONAL PKWY E
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34240-8411
Mailing Address - Country:US
Mailing Address - Phone:941-758-3140
Mailing Address - Fax:941-870-4891
Practice Address - Street 1:6977 PROFESSIONAL PKWY E
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34240
Practice Address - Country:US
Practice Address - Phone:941-758-3140
Practice Address - Fax:941-870-4891
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5010235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL888680600OtherMEDICAID NUMBER