Provider Demographics
NPI:1134603533
Name:SOUTHERLAND, JENA LEIGH (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:JENA
Middle Name:LEIGH
Last Name:SOUTHERLAND
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:JENA
Other - Middle Name:LEIGH
Other - Last Name:BRUNO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1271 OLD US 1 HWY UNIT B
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-6308
Mailing Address - Country:US
Mailing Address - Phone:910-310-9479
Mailing Address - Fax:910-500-5173
Practice Address - Street 1:1271 OLD US 1 HWY UNIT B
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-6308
Practice Address - Country:US
Practice Address - Phone:910-310-9479
Practice Address - Fax:910-500-5173
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12927235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist