Provider Demographics
NPI:1639316722
Name:MEDLOCK, JENNIFER ALYX (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ALYX
Last Name:MEDLOCK
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 CEDAR HILL DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008-9428
Mailing Address - Country:US
Mailing Address - Phone:505-238-4445
Mailing Address - Fax:
Practice Address - Street 1:20 CEDAR HILL DR
Practice Address - Street 2:
Practice Address - City:CEDAR CREST
Practice Address - State:NM
Practice Address - Zip Code:87008-9428
Practice Address - Country:US
Practice Address - Phone:505-238-4445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-12
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3165235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist