Provider Demographics
NPI:1457656605
Name:BROWN, JENNIFER LYNN (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:BROWN
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16109 BLANCO LN
Mailing Address - Street 2:
Mailing Address - City:JUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:76247-6708
Mailing Address - Country:US
Mailing Address - Phone:405-816-3526
Mailing Address - Fax:
Practice Address - Street 1:16109 BLANCO LN
Practice Address - Street 2:
Practice Address - City:JUSTIN
Practice Address - State:TX
Practice Address - Zip Code:76247-6708
Practice Address - Country:US
Practice Address - Phone:405-816-3526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-19
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3593235Z00000X
TX106602235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX330902301Medicaid
82S869OtherBLUE CROSS BLUE SHIELD