Provider Demographics
NPI:1437618667
Name:CARLSON, JENNIFER MARIE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629S STATE HIGHWAY M149
Mailing Address - Street 2:
Mailing Address - City:MANISTIQUE
Mailing Address - State:MI
Mailing Address - Zip Code:49854-8918
Mailing Address - Country:US
Mailing Address - Phone:906-286-2998
Mailing Address - Fax:
Practice Address - Street 1:7870W US HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:MANISTIQUE
Practice Address - State:MI
Practice Address - Zip Code:49854-1599
Practice Address - Country:US
Practice Address - Phone:906-341-3254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101008729235Z00000X
AK1445442355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant