Provider Demographics
NPI:1801018130
Name:MALKOVICH, JENNIFER SHACKELFORD (AUD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:SHACKELFORD
Last Name:MALKOVICH
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:ANNE
Other - Last Name:SHACKELFORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AUD
Mailing Address - Street 1:400 30TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3306
Mailing Address - Country:US
Mailing Address - Phone:510-832-4056
Mailing Address - Fax:510-832-8507
Practice Address - Street 1:400 30TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3306
Practice Address - Country:US
Practice Address - Phone:510-832-4056
Practice Address - Fax:510-832-8507
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU2449231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist