=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134501273
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER HUESMAN LOFTIS M.A., CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2015
-----------------------------------------------------
Last Update Date | 06/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 292 S PINE ST # B
-----------------------------------------------------
City | SPARTANBURG
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29302-2673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-591-3484
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 292 S PINE ST # B
-----------------------------------------------------
City | SPARTANBURG
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29302-2673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-591-3484
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 5497
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------