Provider Demographics
NPI:1245367069
Name:FERNALD, JOLEEN
Entity type:Individual
Prefix:
First Name:JOLEEN
Middle Name:
Last Name:FERNALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 KINSMERE DR
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-4531
Mailing Address - Country:US
Mailing Address - Phone:603-498-7825
Mailing Address - Fax:888-501-7019
Practice Address - Street 1:2114 SEVEN SPRINGS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-3934
Practice Address - Country:US
Practice Address - Phone:603-498-7825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA12821235Z00000X
NH0756235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH389051OtherMVP
NH66Y010671NH01OtherANTHEM