Provider Demographics
NPI:1083300917
Name:VANDERVATE, JENNIFER (HIS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:VANDERVATE
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1948 TANGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4183
Mailing Address - Country:US
Mailing Address - Phone:765-586-0817
Mailing Address - Fax:
Practice Address - Street 1:2825 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-1701
Practice Address - Country:US
Practice Address - Phone:765-447-0131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN17001595A237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist