Provider Demographics
NPI:1689245177
Name:DAVIS, JENNIFER MARIE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:DAVIS
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 1:97 RANDOLPH DR
Mailing Address - Street 2:
Mailing Address - City:NEW CUMBERLAND
Mailing Address - State:WV
Mailing Address - Zip Code:26047-3186
Mailing Address - Country:US
Mailing Address - Phone:304-544-7397
Mailing Address - Fax:
Practice Address - Street 1:901 HERON OAKS LOOP UNIT 8108
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-8787
Practice Address - Country:US
Practice Address - Phone:304-544-7397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL61220563235Z00000X
TX120072235Z00000X
WVSLP-2106235Z00000X
GASLP011637235Z00000X
SC7277235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist