Provider Demographics
NPI:1457304768
Name:MCQUILLAN, JENNIFER (SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MCQUILLAN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17055-2771
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 LONGSDORF WAY
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:PA
Practice Address - Zip Code:17015-7623
Practice Address - Country:US
Practice Address - Phone:717-240-6025
Practice Address - Fax:717-240-6042
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL005895L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASL005895LOtherSTATE LICENSE