Provider Demographics
NPI:1174037865
Name:JENNINGS, RANDY (CCC/SLP)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 S COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-5054
Mailing Address - Country:US
Mailing Address - Phone:540-389-0130
Mailing Address - Fax:540-389-3638
Practice Address - Street 1:510 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-5054
Practice Address - Country:US
Practice Address - Phone:540-389-0130
Practice Address - Fax:540-389-3638
Is Sole Proprietor?:No
Enumeration Date:2017-11-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202003350235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist