Provider Demographics
NPI:1225019094
Name:ROSENTHAL-DIBB, JENNIFER L (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:ROSENTHAL-DIBB
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 1:4602 CUMBERLAND RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-2412
Mailing Address - Country:US
Mailing Address - Phone:910-423-5622
Mailing Address - Fax:910-378-1755
Practice Address - Street 1:4602 CUMBERLAND RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28306-2412
Practice Address - Country:US
Practice Address - Phone:910-423-5622
Practice Address - Fax:910-423-5538
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3200235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7464046Medicaid
NC1156EOtherBLUE CROSS/BLUE SHIELD