MEDICARE: MRS. JENNIFER SHERIDAN 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	011157-1	NY

General Provider Information

NPI Number	:	1285942367
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER SHERIDAN CCC-SLP

Provider Business Mailing Address
First Line	:	376 PITTSBURG AVE
Second Line	:
City	:	MASSAPEQUA PARK
State	:	NY
Zip	:	11762-1840
Country	:	US
Telephone Number	:	516-797-7708
Fax Number	:

Provider Business Practice Location Address
First Line	:	376 PITTSBURG AVE
Second Line	:
City	:	MASSAPEQUA PARK
State	:	NY
Zip	:	11762-1840
Country	:	US
Telephone Number	:	516-797-7708
Fax Number	:

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

Provider Enumeration Date	:	09/22/2010
Last Update Date	:	09/22/2010

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