Provider Demographics
NPI:1164565214
Name:AUTENRIETH, JENNIFER LISA (MA CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LISA
Last Name:AUTENRIETH
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 MABBETTE STREET
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741
Mailing Address - Country:US
Mailing Address - Phone:407-201-8079
Mailing Address - Fax:407-343-9180
Practice Address - Street 1:1107 MABBETTE STREET
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741
Practice Address - Country:US
Practice Address - Phone:407-201-8079
Practice Address - Fax:407-343-9180
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 7468235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018229600Medicaid