Provider Demographics
NPI:1114066198
Name:DORMACK, JENNIFER HELEN (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:HELEN
Last Name:DORMACK
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 KNOLLCREST RD
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767-2810
Mailing Address - Country:US
Mailing Address - Phone:917-822-7321
Mailing Address - Fax:
Practice Address - Street 1:8 KNOLLCREST RD
Practice Address - Street 2:
Practice Address - City:NESCONSET
Practice Address - State:NY
Practice Address - Zip Code:11767-2810
Practice Address - Country:US
Practice Address - Phone:917-822-7321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012651-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist