Provider Demographics
NPI:1427225291
Name:EWALT, JENNIE P (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:P
Last Name:EWALT
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 1:13182 MISTY CT
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-5268
Mailing Address - Country:US
Mailing Address - Phone:303-503-5724
Mailing Address - Fax:
Practice Address - Street 1:13182 MISTY CT
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020
Practice Address - Country:US
Practice Address - Phone:303-503-5724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-12
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12085674235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist