Provider Demographics
NPI:1477991990
Name:BASS, JENNIFER MICHELLE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:BASS
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 1:2765 JEFFERSON DAVIS HWY
Mailing Address - Street 2:SUITE 209
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-8331
Mailing Address - Country:US
Mailing Address - Phone:540-720-2261
Mailing Address - Fax:540-720-5660
Practice Address - Street 1:13890 BRADDOCK RD
Practice Address - Street 2:SUITE 205
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2435
Practice Address - Country:US
Practice Address - Phone:540-720-2261
Practice Address - Fax:540-720-5660
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202007003235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist