MEDICARE: JENNIE LYNN M.A. CCC/SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SP694	NV

General Provider Information

NPI Number	:	1013153394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIE LYNN M.A. CCC/SLP

Provider Business Mailing Address
First Line	:	6152 CALM BREEZE AVE
Second Line	:	UNIT 103
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-5192
Country	:	US
Telephone Number	:	702-645-8243
Fax Number	:

Provider Business Practice Location Address
First Line	:	6152 CALM BREEZE AVE
Second Line	:	UNIT 103
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-5192
Country	:	US
Telephone Number	:	702-645-8243
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/17/2008
Last Update Date	:	12/17/2008

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