Provider Demographics
NPI:1477848745
Name:ALICEA, JENNIFER LEE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LEE
Last Name:ALICEA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:LEE
Other - Last Name:GENDREAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:401 VENTURE DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-3478
Mailing Address - Country:US
Mailing Address - Phone:866-973-1043
Mailing Address - Fax:866-600-5445
Practice Address - Street 1:401 VENTURE DR
Practice Address - Street 2:SUITE C
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-3478
Practice Address - Country:US
Practice Address - Phone:866-973-1043
Practice Address - Fax:866-600-5445
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8022235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist