Provider Demographics
NPI:1780647610
Name:REIDENBACH, JENNIFER ALLLISON (MSR, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ALLLISON
Last Name:REIDENBACH
Suffix:
Gender:F
Credentials:MSR, CCC-SLP
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:ALLISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSR, CCC-SLP
Mailing Address - Street 1:1233 BEN SAWYER BLVD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-4577
Mailing Address - Country:US
Mailing Address - Phone:843-697-0396
Mailing Address - Fax:864-640-8011
Practice Address - Street 1:1233 BEN SAWYER BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-4577
Practice Address - Country:US
Practice Address - Phone:843-697-0396
Practice Address - Fax:864-640-8011
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3695235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0617Medicaid
SCQ339168280Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER ID