Provider Demographics
NPI:1710335591
Name:DORMAN, JENNA BROOKE (MS SLP)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:BROOKE
Last Name:DORMAN
Suffix:
Gender:F
Credentials:MS SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 SMALLHOUSE RD
Mailing Address - Street 2:APT D
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3284
Mailing Address - Country:US
Mailing Address - Phone:813-495-4335
Mailing Address - Fax:
Practice Address - Street 1:1700 SMALLHOUSE RD
Practice Address - Street 2:APT D
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3284
Practice Address - Country:US
Practice Address - Phone:813-495-4335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY167781235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist