Provider Demographics
NPI:1558689562
Name:SELF, JENNIFER KAY (MS CCC/SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KAY
Last Name:SELF
Suffix:
Gender:F
Credentials:MS CCC/SLP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ELLEN
Other - Last Name:KAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC/SLP
Mailing Address - Street 1:2222 SULLIVAN TRL
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18040-7958
Mailing Address - Country:US
Mailing Address - Phone:800-944-9782
Mailing Address - Fax:610-438-2024
Practice Address - Street 1:1260 HIGHTOWER TRL
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30350-6248
Practice Address - Country:US
Practice Address - Phone:770-594-3434
Practice Address - Fax:770-594-3434
Is Sole Proprietor?:No
Enumeration Date:2010-05-14
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005598235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist