Provider Demographics
NPI:1811389992
Name:BENNETT, JENNIFER (MA, CCC/SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BENNETT
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 1:4500 LAKEKNOLL ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44641-9627
Mailing Address - Country:US
Mailing Address - Phone:330-575-0463
Mailing Address - Fax:
Practice Address - Street 1:415 N NICKELPLATE ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:OH
Practice Address - Zip Code:44641-1567
Practice Address - Country:US
Practice Address - Phone:330-875-1177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-25
Last Update Date:2015-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.5466235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist