Provider Demographics
NPI:1609001007
Name:CHAMPAGNE, JENNIFER ANNE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANNE
Last Name:CHAMPAGNE
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 1:31 STATE ST
Mailing Address - Street 2:
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12953-2411
Mailing Address - Country:US
Mailing Address - Phone:518-483-3608
Mailing Address - Fax:
Practice Address - Street 1:31 STATE ST
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-2411
Practice Address - Country:US
Practice Address - Phone:518-483-3608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-28
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017288235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist