Provider Demographics
NPI:1255712550
Name:MYRICK, JENNIFER L (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:MYRICK
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 1:1008 E 34TH ST
Mailing Address - Street 2:
Mailing Address - City:BAXTER SPRINGS
Mailing Address - State:KS
Mailing Address - Zip Code:66713-2914
Mailing Address - Country:US
Mailing Address - Phone:918-541-3121
Mailing Address - Fax:
Practice Address - Street 1:310 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-6743
Practice Address - Country:US
Practice Address - Phone:918-540-7736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2963235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist