Provider Demographics
NPI:1316010325
Name:KWAST, JENNIFER SUSAN (MA,CCC-A)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:SUSAN
Last Name:KWAST
Suffix:
Gender:F
Credentials:MA,CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1984 DEL CIERVO PL
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-4067
Mailing Address - Country:US
Mailing Address - Phone:616-915-0825
Mailing Address - Fax:
Practice Address - Street 1:2438 N PONDEROSA DR
Practice Address - Street 2:C110
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-2369
Practice Address - Country:US
Practice Address - Phone:805-484-5951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000224231H00000X
CAAU1716231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist