Provider Demographics
NPI:1912321852
Name:GRANTHAM, JENNIFER ANN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:GRANTHAM
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4208 COLUMBINE DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78727-2601
Mailing Address - Country:US
Mailing Address - Phone:512-507-6115
Mailing Address - Fax:
Practice Address - Street 1:9707 ANDERSON MILL RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-2298
Practice Address - Country:US
Practice Address - Phone:512-827-7011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103749235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist