Provider Demographics
NPI:1619209467
Name:THOMPSON-MACKOVJAK, JENNIFER LYNN (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:THOMPSON-MACKOVJAK
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:CENTRAL MICHIGAN UNIVERSITY
Mailing Address - Street 2:1101 HEALTH PROFESSIONS BLDG
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48859-0001
Mailing Address - Country:US
Mailing Address - Phone:989-774-3904
Mailing Address - Fax:989-774-1891
Practice Address - Street 1:CENTRAL MICHIGAN UNIVERSITY
Practice Address - Street 2:1101 HEALTH PROFESSIONS BLDG
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48859-0001
Practice Address - Country:US
Practice Address - Phone:989-774-3904
Practice Address - Fax:989-774-1891
Is Sole Proprietor?:No
Enumeration Date:2010-02-04
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI12117133OtherASHA
MI7101004151OtherLICENSE