Provider Demographics
NPI:1568238483
Name:FOUNTAIN, JALEN LEE
Entity Type:Individual
Prefix:
First Name:JALEN
Middle Name:LEE
Last Name:FOUNTAIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2776 CHERRY GROVE RD
Mailing Address - Street 2:
Mailing Address - City:YANCEYVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27379-9194
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:159 EXECUTIVE DR STE DANVILLE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-4160
Practice Address - Country:US
Practice Address - Phone:434-799-7732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant