Provider Demographics
NPI:1831324433
Name:MOULTON, JEFFREY GLENN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:GLENN
Last Name:MOULTON
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
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Mailing Address - Street 1:7025 SIERRA CLUB CIR APT 6105
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34113-7360
Mailing Address - Country:US
Mailing Address - Phone:734-351-8503
Mailing Address - Fax:
Practice Address - Street 1:7025 SIERRA CLUB CIR APT 6105
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34113-7360
Practice Address - Country:US
Practice Address - Phone:734-351-8503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA15131235Z00000X
MI235Z00000X
MI7101004036235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7101004036OtherMICHIGAN LICENSE
FLSA15131OtherFLORIDA LICENSE