Healthcare Provider Details

I. General information

NPI: 1730583774
Provider Name (Legal Business Name): JENNIFER VAZIRIAN CCC SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2014
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8519 RIDGE STONE ST
SAN ANTONIO TX
78251-2203
US

IV. Provider business mailing address

8403 STATE HIGHWAY 151 STE 104
SAN ANTONIO TX
78245-2055
US

V. Phone/Fax

Practice location:
  • Phone: 210-779-3592
  • Fax: 210-520-0464
Mailing address:
  • Phone: 210-779-3592
  • Fax: 210-520-0464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number0188501
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number109362
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: