Provider Demographics
NPI:1821463092
Name:JUBILEE PEDIATRIC SPEECH SERVICES, LLC
Entity Type:Organization
Organization Name:JUBILEE PEDIATRIC SPEECH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:G
Authorized Official - Last Name:FORAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, CCC-SLP
Authorized Official - Phone:251-340-2166
Mailing Address - Street 1:9086 MERRITT LN
Mailing Address - Street 2:SUITE D
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-5612
Mailing Address - Country:US
Mailing Address - Phone:251-340-2166
Mailing Address - Fax:251-405-3416
Practice Address - Street 1:9086 MERRITT LN
Practice Address - Street 2:SUITE D
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-5612
Practice Address - Country:US
Practice Address - Phone:251-340-2166
Practice Address - Fax:251-405-3416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-14
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2955235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1518101047Medicaid