Healthcare Provider Details

I. General information

NPI: 1962139188
Provider Name (Legal Business Name): SAMANTHA RAE JENNINGS MA-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2022
Last Update Date: 08/07/2022
Certification Date: 08/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 IVY DR
NORTH NEWTON KS
67117-8001
US

IV. Provider business mailing address

641 N BURNS AVE
VALLEY CENTER KS
67147-2626
US

V. Phone/Fax

Practice location:
  • Phone: 316-284-2900
  • Fax:
Mailing address:
  • Phone: 620-655-2233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3815
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: