Provider Demographics
NPI:1578774915
Name:WOODALL, JENNIFER LEAH
Entity Type:Individual
Prefix:MR
First Name:JENNIFER
Middle Name:LEAH
Last Name:WOODALL
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 1:1965 BOTANICA CIRCLE
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904
Mailing Address - Country:US
Mailing Address - Phone:321-409-9266
Mailing Address - Fax:321-409-9266
Practice Address - Street 1:1965 BOTANICA CIRCLE
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904
Practice Address - Country:US
Practice Address - Phone:321-409-9266
Practice Address - Fax:321-409-9266
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 6637235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist