Provider Demographics
NPI:1295013449
Name:ANDERSON, JENNIFER (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3431 VAUX ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1436
Mailing Address - Country:US
Mailing Address - Phone:201-519-1815
Mailing Address - Fax:
Practice Address - Street 1:3431 VAUX ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19129-1436
Practice Address - Country:US
Practice Address - Phone:201-519-1815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL007035235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist