Provider Demographics
NPI:1538294905
Name:PROUT, JENNIFER (SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PROUT
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:ME
Mailing Address - Zip Code:04648-0069
Mailing Address - Country:US
Mailing Address - Phone:207-434-6116
Mailing Address - Fax:
Practice Address - Street 1:1326 US ROUTE 1
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:ME
Practice Address - Zip Code:04648
Practice Address - Country:US
Practice Address - Phone:207-434-6116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP1200235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME098552OtherANTHEM BCBS PROVIDER #