Provider Demographics
NPI:1457882441
Name:SAMUELSON, JOLENE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:
Last Name:SAMUELSON
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 1:1202 E JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-3866
Mailing Address - Country:US
Mailing Address - Phone:307-856-4337
Mailing Address - Fax:
Practice Address - Street 1:1202 E JACKSON AVE
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-3866
Practice Address - Country:US
Practice Address - Phone:307-856-4337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYSP-652235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist