Provider Demographics
NPI:1740429935
Name:MILLS, JENNIFER ANN (MA,CCC/SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:MILLS
Suffix:
Gender:F
Credentials:MA,CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 STATE ST
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-3352
Mailing Address - Country:US
Mailing Address - Phone:315-393-0900
Mailing Address - Fax:
Practice Address - Street 1:1100 STATE ST
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-3352
Practice Address - Country:US
Practice Address - Phone:315-393-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025670235Z00000X
TX102304235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0046NNOtherBLUE CROSS BLUE SHIELD
TX0046NNOtherMEDICARE PART B
TX676617OtherMEDICARE PART A
TX178709501Medicaid