MEDICARE: MRS. JENNIFER CHRISTINE KUDSIN PARENT M, CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	4918	SC

General Provider Information

NPI Number	:	1780964569
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER CHRISTINE KUDSIN PARENT M, CCC-SLP

Provider Business Mailing Address
First Line	:	2210 PUTNAM DR UNIT 128
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-1742
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8703 HIGHWAY 17 BYP S STE I
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29575-7701
Country	:	US
Telephone Number	:	843-457-1053
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2011
Last Update Date	:	02/01/2013

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