Provider Demographics
NPI:1821713637
Name:BANOVIC, JENNIFER RAE (AUD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAE
Last Name:BANOVIC
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12380 OLIVE BLVD
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6443
Mailing Address - Country:US
Mailing Address - Phone:314-384-5454
Mailing Address - Fax:636-238-4388
Practice Address - Street 1:12380 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6443
Practice Address - Country:US
Practice Address - Phone:314-384-8088
Practice Address - Fax:636-238-4388
Is Sole Proprietor?:No
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022038462231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist