Healthcare Provider Details

I. General information

NPI: 1437618667
Provider Name (Legal Business Name): JENNIFER MARIE CARLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 01/05/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7870W US HIGHWAY 2
MANISTIQUE MI
49854-1599
US

IV. Provider business mailing address

629S STATE HIGHWAY M149
MANISTIQUE MI
49854-8918
US

V. Phone/Fax

Practice location:
  • Phone: 906-341-3254
  • Fax:
Mailing address:
  • Phone: 906-286-2998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101008729
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number144544
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: