Provider Demographics
NPI:1417093337
Name:DOUGLAS, JENNY LYNN (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:LYNN
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5935 NW 93RD TER
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-4164
Mailing Address - Country:US
Mailing Address - Phone:704-654-8930
Mailing Address - Fax:
Practice Address - Street 1:5935 NW 93RD TER
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-4164
Practice Address - Country:US
Practice Address - Phone:704-654-8930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 12015235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist