Provider Demographics
NPI:1972804482
Name:SHAGAN, JENNIFER MARY (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:MARY
Last Name:SHAGAN
Suffix:
Gender:F
Credentials:MS 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:PO BOX 362
Mailing Address - Street 2:
Mailing Address - City:POUGHQUAG
Mailing Address - State:NY
Mailing Address - Zip Code:12570-0362
Mailing Address - Country:US
Mailing Address - Phone:845-702-6159
Mailing Address - Fax:
Practice Address - Street 1:15 MOUNT EBO RD S
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:NY
Practice Address - Zip Code:10509-4004
Practice Address - Country:US
Practice Address - Phone:845-878-9078
Practice Address - Fax:845-278-6984
Is Sole Proprietor?:No
Enumeration Date:2010-11-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020586-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist