Provider Demographics
NPI:1962636506
Name:WHITAKER, JENNIE L (MA CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JENNIE
Middle Name:L
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:968 BAYOU TRACE DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-2554
Mailing Address - Country:US
Mailing Address - Phone:318-308-4752
Mailing Address - Fax:
Practice Address - Street 1:968 BAYOU TRACE DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-2554
Practice Address - Country:US
Practice Address - Phone:318-308-4752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1644235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAJWHITAKER49OtherBLUE CROSS/ BLUE SHIELD
LAJWHITAKER49Medicaid
LAJWHITAKER49Medicare UPIN