Provider Demographics
NPI:1780862490
Name:KEPHART, JENNIFER L (SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:KEPHART
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2295 HENRY CLOWER BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-5707
Mailing Address - Country:US
Mailing Address - Phone:770-995-9600
Mailing Address - Fax:678-383-4556
Practice Address - Street 1:2295 HENRY CLOWER BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-5707
Practice Address - Country:US
Practice Address - Phone:770-995-9600
Practice Address - Fax:678-383-4556
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-05
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005990235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist