Provider Demographics
NPI:1619095544
Name:PROVANCE, JEANNETTE G
Entity Type:Individual
Prefix:MS
First Name:JEANNETTE
Middle Name:G
Last Name:PROVANCE
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 1:505 BURKHART
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MO
Mailing Address - Zip Code:63863
Mailing Address - Country:US
Mailing Address - Phone:573-276-5791
Mailing Address - Fax:573-276-4993
Practice Address - Street 1:505 BURKHART
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MO
Practice Address - Zip Code:63863
Practice Address - Country:US
Practice Address - Phone:573-276-5791
Practice Address - Fax:573-276-4993
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0334890235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist