Provider Demographics
NPI:1891981932
Name:DRAKE, JENNIFER (MCD, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DRAKE
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 COUNTY ROAD 457
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-8225
Mailing Address - Country:US
Mailing Address - Phone:870-219-3867
Mailing Address - Fax:
Practice Address - Street 1:116 COUNTY ROAD 457
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-8225
Practice Address - Country:US
Practice Address - Phone:870-219-3867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#2054235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR149650721Medicaid