Provider Demographics
NPI:1912159286
Name:RUDOLPH, JENNIFER (MS, CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:
Last Name:RUDOLPH
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 1:1185 COLLIER RD NW
Mailing Address - Street 2:APT 2129
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-8232
Mailing Address - Country:US
Mailing Address - Phone:205-492-2507
Mailing Address - Fax:678-922-2267
Practice Address - Street 1:1185 COLLIER RD NW
Practice Address - Street 2:APT 2129
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-8232
Practice Address - Country:US
Practice Address - Phone:205-492-2507
Practice Address - Fax:678-922-2267
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-17
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006778235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist