Provider Demographics
NPI:1942577689
Name:SUND, JENNIFER RYAN (SLP-CCC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:RYAN
Last Name:SUND
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:RYAN
Other - Last Name:WILDHABER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP-CCC
Mailing Address - Street 1:914 S SCHEUBER ROAD
Mailing Address - Street 2:PROVIDENCE CENTRALIA HOSPITAL
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98532
Mailing Address - Country:US
Mailing Address - Phone:360-330-8720
Mailing Address - Fax:360-330-8737
Practice Address - Street 1:914 S SCHEUBER ROAD
Practice Address - Street 2:PROVIDENCE CENTRALIA HOSPITAL
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98532
Practice Address - Country:US
Practice Address - Phone:360-330-8720
Practice Address - Fax:360-330-8737
Is Sole Proprietor?:No
Enumeration Date:2011-11-23
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60025586235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist