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General NPI Number Information
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NPI Number | 1669845392
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Entity Type | Individual
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Provider Name | JENNIFER CULLEN
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Gender | Female
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Dates
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Enumeration Date | 11/03/2015
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Last Update Date | 11/03/2015
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Provider Practice Location Address
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Address Line | 2608 FIELDSTONE DR
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City | MARYVILLE
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State | IL
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Zip | 62062-6433
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Country | US
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Telephone | 618-363-9675
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Fax |
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Provider Business Mailing Address
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Address Line | 2608 FIELDSTONE DR
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City | MARYVILLE
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State | IL
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Zip | 62062-6433
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Country | US
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Telephone | 618-363-9675
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 146.006564
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SP 20740
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 0325431
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License Number State | MO
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