Provider Demographics
NPI:1417087115
Name:MACKFOUNTAIN, JENNIFER A (MSP, CCC, SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:MACKFOUNTAIN
Suffix:
Gender:F
Credentials:MSP, CCC, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7601 SE TETON DR
Mailing Address - Street 2:
Mailing Address - City:HOBE SOUND
Mailing Address - State:FL
Mailing Address - Zip Code:33455-7884
Mailing Address - Country:US
Mailing Address - Phone:772-287-1007
Mailing Address - Fax:
Practice Address - Street 1:7601 SE TETON DR
Practice Address - Street 2:
Practice Address - City:HOBE SOUND
Practice Address - State:FL
Practice Address - Zip Code:33455-7884
Practice Address - Country:US
Practice Address - Phone:772-287-1007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA1616235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist