Provider Demographics
NPI:1376662791
Name:MOLLERUP, JENNIE LYNN (AUD, CCC-A)
Entity Type:Individual
Prefix:DR
First Name:JENNIE
Middle Name:LYNN
Last Name:MOLLERUP
Suffix:
Gender:F
Credentials:AUD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 S MAIN ST # 29
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-9755
Mailing Address - Country:US
Mailing Address - Phone:509-322-5995
Mailing Address - Fax:
Practice Address - Street 1:506 RIVERSIDE DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841
Practice Address - Country:US
Practice Address - Phone:509-826-7165
Practice Address - Fax:509-826-1179
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT56420554101231H00000X
WALD60323941237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist