Provider Demographics
NPI:1497998207
Name:SULLIVAN, JENNIFER R (MS,CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:R
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 HERBERT AVE
Mailing Address - Street 2:
Mailing Address - City:FANWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07023-1643
Mailing Address - Country:US
Mailing Address - Phone:908-889-5309
Mailing Address - Fax:
Practice Address - Street 1:161 HERBERT AVE
Practice Address - Street 2:
Practice Address - City:FANWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07023
Practice Address - Country:US
Practice Address - Phone:908-889-5309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0179561235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist