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NPI Code Detail

MEDICARE: MRS. JENNIFER MARIE WIDENER MCD, CCC-SLP

MEDICARE: MRS. JENNIFER MARIE WIDENER MCD, 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
1235Z00000XSpeech-Language Pathologist3296AL

General Provider Information

NPI Number : 1366809477
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. JENNIFER MARIE WIDENER MCD, CCC-SLP
Provider Business Mailing Address
First Line : 6 STONERIDGE RD
Second Line :
City : CATAULA
State : GA
Zip : 31804-2130
Country : US
Telephone Number : 229-224-6826
Fax Number :
Provider Business Practice Location Address
First Line : 1720 KNOWLES RD
Second Line :
City : PHENIX CITY
State : AL
Zip : 36869-7135
Country : US
Telephone Number : 334-291-0485
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/20/2016
Last Update Date : 01/20/2016

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