MEDICARE: JOLEEN FERNALD

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	SA12821	FL
2	235Z00000X	Speech-Language Pathologist	0756	NH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	389051	OTHER	NH	MVP
2	66Y010671NH01	OTHER	NH	ANTHEM

General Provider Information

NPI Number	:	1245367069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOLEEN FERNALD

Provider Business Mailing Address
First Line	:	1820 KINSMERE DR
Second Line	:
City	:	TRINITY
State	:	FL
Zip	:	34655-4531
Country	:	US
Telephone Number	:	603-498-7825
Fax Number	:	888-501-7019

Provider Business Practice Location Address
First Line	:	2114 SEVEN SPRINGS BLVD STE 200
Second Line	:
City	:	TRINITY
State	:	FL
Zip	:	34655-3934
Country	:	US
Telephone Number	:	603-498-7825
Fax Number	:

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

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	10/04/2022

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Directions to “ JOLEEN FERNALD ” Practice Location

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