Provider Demographics
NPI:1619025459
Name:KRUTZ, JENNIFER K (ST)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:KRUTZ
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 S BOLIVAR AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-3244
Mailing Address - Country:US
Mailing Address - Phone:662-843-2339
Mailing Address - Fax:662-846-1397
Practice Address - Street 1:308 S BOLIVAR AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-3244
Practice Address - Country:US
Practice Address - Phone:662-843-2339
Practice Address - Fax:662-846-1397
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2937235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09070080Medicaid