Provider Demographics
NPI:1205818275
Name:EHNSTROM, JANE A (CCC A)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:A
Last Name:EHNSTROM
Suffix:
Gender:F
Credentials:CCC A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 ELM ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-2541
Mailing Address - Country:US
Mailing Address - Phone:508-757-0330
Mailing Address - Fax:508-754-9426
Practice Address - Street 1:48 ELM ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-2541
Practice Address - Country:US
Practice Address - Phone:508-757-0330
Practice Address - Fax:508-754-9426
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA324231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AA3440OtherHARVARD PILGRIM HEALTHCAR
AD0171OtherBLUE SHIELD IDEMNITY
042472266OtherTHREE RIVERS
7941616OtherAETNA US HEALTHCARE
AD0171OtherBLUE SHIELD HMO BLUE
042472266039OtherTRICARE CHAMPUS
AD0171OtherBLUE CARE ELECT
54936OtherFALLON COMMUNITY HEALTH P
042472266OtherONE HEALTH PLAN
MA5104424Medicaid
042472266OtherUNITED HEALTHCARE
042472266OtherONE HEALTH PLAN
011364Medicare ID - Type UnspecifiedMEDICARE B