Provider Demographics
NPI:1699203299
Name:BURTTRAM, JENNINGS
Entity Type:Individual
Prefix:
First Name:JENNINGS
Middle Name:
Last Name:BURTTRAM
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 1:45 SYCAMORE AVE APT 828
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-6727
Mailing Address - Country:US
Mailing Address - Phone:843-909-0363
Mailing Address - Fax:
Practice Address - Street 1:1127 QUEENSBOROUGH BLVD STE 104
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-5431
Practice Address - Country:US
Practice Address - Phone:184-321-6272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-25
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist