Provider Demographics
NPI:1083179915
Name:MANFRE, JAIMIE LYNN (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JAIMIE
Middle Name:LYNN
Last Name:MANFRE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:MS
Other - First Name:JAIMIE
Other - Middle Name:LYNN
Other - Last Name:MEDEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:37333 BRISTOL ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-1763
Mailing Address - Country:US
Mailing Address - Phone:734-751-8814
Mailing Address - Fax:
Practice Address - Street 1:46200 PORT ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-6048
Practice Address - Country:US
Practice Address - Phone:734-454-0866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101005177235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist