Provider Demographics
NPI:1255872834
Name:BLUE JELLYFISH LLC
Entity type:Organization
Organization Name:BLUE JELLYFISH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:MOIRA
Authorized Official - Last Name:HASTING
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:410-733-1405
Mailing Address - Street 1:5525 TWIN KNOLLS RD STE 325
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-3203
Mailing Address - Country:US
Mailing Address - Phone:410-733-1405
Mailing Address - Fax:
Practice Address - Street 1:11241 SKILIFT CT UNIT A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3094
Practice Address - Country:US
Practice Address - Phone:410-733-1405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-15
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06143261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech