Provider Demographics
NPI:1235605098
Name:KING, JENNIFER NICHOLE (MA)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:NICHOLE
Last Name:KING
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7474 E EARLL DR UNIT 112
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-7922
Mailing Address - Country:US
Mailing Address - Phone:614-572-5311
Mailing Address - Fax:
Practice Address - Street 1:25615 N RANCH GATE RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-2141
Practice Address - Country:US
Practice Address - Phone:480-502-7726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-19
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP11526235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZSLP11526OtherTEMPORARY LICENSE AS SPEECH LANGUAGE PATHOLOGIST