Provider Demographics
NPI:1912153446
Name:IVEY, JENNIFER BROOKE (MS)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:BROOKE
Last Name:IVEY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 HARDY AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-1923
Mailing Address - Country:US
Mailing Address - Phone:520-591-2248
Mailing Address - Fax:
Practice Address - Street 1:828 S BASCOM AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2651
Practice Address - Country:US
Practice Address - Phone:408-793-5959
Practice Address - Fax:408-793-4244
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP5956235Z00000X
GASLP007374235Z00000X
CA21975235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist