MEDICARE: MRS. JENNIFER L MOAK MACCCSLP

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	SL007314	PA

General Provider Information

NPI Number	:	1417148982
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER L MOAK MACCCSLP

Provider Business Mailing Address
First Line	:	1624 DUFFIELD ST
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15206-1323
Country	:	US
Telephone Number	:	412-362-6216
Fax Number	:

Provider Business Practice Location Address
First Line	:	3394 SAXONBURG BLVD
Second Line	:	SUITE 620
City	:	GLENSHAW
State	:	PA
Zip	:	15116-3168
Country	:	US
Telephone Number	:	412-963-0463
Fax Number	:

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

Provider Enumeration Date	:	08/08/2007
Last Update Date	:	12/16/2008

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Directions to “ MRS. JENNIFER L MOAK MACCCSLP” Practice Location

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