Provider Demographics
NPI:1801063177
Name:RAULERSON, JENNIFER L (SLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:RAULERSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 673
Mailing Address - Street 2:
Mailing Address - City:PATTERSON
Mailing Address - State:GA
Mailing Address - Zip Code:31557-0673
Mailing Address - Country:US
Mailing Address - Phone:706-614-2248
Mailing Address - Fax:706-353-1606
Practice Address - Street 1:2019 ALICE ST
Practice Address - Street 2:SUITE B
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-6209
Practice Address - Country:US
Practice Address - Phone:706-614-2248
Practice Address - Fax:706-353-1606
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005585235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52058554002OtherBCBS OF GA
GA833369342AMedicaid
GA344381OtherWELLCARE HEALTH - GA REGION
GA10080845OtherAMERIGROUP COMMUNITY CARE
GA581834332005OtherATHENS AREA HEALTH PLAN SELECT
GA344381OtherWELLCARE HEALTH - GA REGION