Provider Demographics
NPI:1326515586
Name:KEARSE, JENNIFER ELAINE (MACCCSLP)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ELAINE
Last Name:KEARSE
Suffix:
Gender:F
Credentials:MACCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:849 TIGER BLVD UNIT 203
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29631-1577
Mailing Address - Country:US
Mailing Address - Phone:706-244-0900
Mailing Address - Fax:
Practice Address - Street 1:813 ATLANTA HWY
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:GA
Practice Address - Zip Code:30828-9105
Practice Address - Country:US
Practice Address - Phone:706-465-3328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP003879235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GASLP003879Medicaid