Provider Demographics
NPI:1467843888
Name:HERTRICH, JENNIFER (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HERTRICH
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 1:1311 MAMARONECK AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-5224
Mailing Address - Country:US
Mailing Address - Phone:914-294-4050
Mailing Address - Fax:
Practice Address - Street 1:740 W GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-2392
Practice Address - Country:US
Practice Address - Phone:810-227-3588
Practice Address - Fax:810-626-4045
Is Sole Proprietor?:No
Enumeration Date:2015-02-06
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP.0001826235Z00000X
MI7101004996235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist