Provider Demographics
NPI:1134179757
Name:FREE, JENNIFER DENISE (MED CCC-SLP/L)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DENISE
Last Name:FREE
Suffix:
Gender:F
Credentials:MED CCC-SLP/L
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:DENISE
Other - Last Name:BRAGG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED CCC-SLP/L
Mailing Address - Street 1:6920 BRADDOCK ROAD
Mailing Address - Street 2:SUITE B618
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003
Mailing Address - Country:US
Mailing Address - Phone:703-910-3321
Mailing Address - Fax:
Practice Address - Street 1:6920 BRADDOCK ROAD
Practice Address - Street 2:SUITE B618
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003
Practice Address - Country:US
Practice Address - Phone:703-910-3321
Practice Address - Fax:703-663-7134
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202005653235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2202005653OtherSTATE LICENSE
09141803OtherASHA CERTIFICATION