Provider Demographics
NPI:1346846318
Name:MEDINA, JENNIFER (SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 W ROMANA ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32502-5723
Mailing Address - Country:US
Mailing Address - Phone:850-602-1877
Mailing Address - Fax:
Practice Address - Street 1:401 E CHASE ST STE 200
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32502-6160
Practice Address - Country:US
Practice Address - Phone:850-476-0628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA11183235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12141814OtherASHA
FLSA11183OtherSTATE OF FL DEPT OF HEALTH
LA8487OtherLOUISIANA BOARD OF EXAMINERS