Provider Demographics
NPI:1255846432
Name:GARDNER, JENNIE NGUYEN
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:NGUYEN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11812 PLEASANT FOREST DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-2454
Mailing Address - Country:US
Mailing Address - Phone:501-765-8360
Mailing Address - Fax:
Practice Address - Street 1:1401 MURRELL TAYLOR DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-8118
Practice Address - Country:US
Practice Address - Phone:501-985-1581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-09
Last Update Date:2017-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP9199235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist