Provider Demographics
NPI:1093321366
Name:FREDENBURG, JENNIFER LOUISE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LOUISE
Last Name:FREDENBURG
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:LOUISE
Other - Last Name:HIRST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:645 TAMALPAIS DR
Mailing Address - Street 2:
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925-1613
Mailing Address - Country:US
Mailing Address - Phone:415-924-2444
Mailing Address - Fax:
Practice Address - Street 1:645 TAMALPAIS DR
Practice Address - Street 2:
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1613
Practice Address - Country:US
Practice Address - Phone:415-924-2444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30530235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist