MEDICARE: MRS. JENEY MAMMEN

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	2355S0801X	Speech-Language Assistant	31471	TX

General Provider Information

NPI Number	:	1821160326
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENEY MAMMEN

Provider Business Mailing Address
First Line	:	962 WISPERWOOD DR
Second Line	:
City	:	ROCKWALL
State	:	TX
Zip	:	75087-2288
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1205 RIDGE RD # A
Second Line	:
City	:	ROCKWALL
State	:	TX
Zip	:	75087-4242
Country	:	US
Telephone Number	:	972-722-7016
Fax Number	:

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

Provider Enumeration Date	:	11/14/2006
Last Update Date	:	07/08/2007

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