Provider Demographics
NPI:1710372883
Name:JENNISON, ANDREW (CF-SLP)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:JENNISON
Suffix:
Gender:M
Credentials:CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25117 SW PARKWAY AVE STE D
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9697
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17201 15TH AVE NE
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-5129
Practice Address - Country:US
Practice Address - Phone:206-364-9336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-05
Last Update Date:2015-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASLPI.SI.60547212235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist