Provider Demographics
NPI:1710580303
Name:SAMUEL, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SAMUEL
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 1:3075 LANDINGTON DR
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-3535
Mailing Address - Country:US
Mailing Address - Phone:860-416-6108
Mailing Address - Fax:
Practice Address - Street 1:4300 CHAPEL HILL RD STE 1000
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-4227
Practice Address - Country:US
Practice Address - Phone:800-381-2195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist