Provider Demographics
NPI:1992847149
Name:VANDENBERGE, JENNIFER (SLP)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:
Last Name:VANDENBERGE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7063 SADDLE DR
Mailing Address - Street 2:
Mailing Address - City:SYKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21784-5936
Mailing Address - Country:US
Mailing Address - Phone:410-549-5501
Mailing Address - Fax:
Practice Address - Street 1:7401 OSLER DR
Practice Address - Street 2:SUITE 110
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7673
Practice Address - Country:US
Practice Address - Phone:410-296-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03549235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD621764OtherBC BS