Provider Demographics
NPI:1326558602
Name:DOUGLAS, JENELL (AUD)
Entity Type:Individual
Prefix:
First Name:JENELL
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 NEWTOWN RD STE 2A
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-4151
Mailing Address - Country:US
Mailing Address - Phone:203-830-4700
Mailing Address - Fax:203-730-4165
Practice Address - Street 1:107 NEWTOWN RD STE 2A
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810
Practice Address - Country:US
Practice Address - Phone:203-830-4700
Practice Address - Fax:203-730-4165
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-02
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT618231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty