MEDICARE: MS. JENNIFER LYNN BLAKE SPEECH LANGUAGE PATH

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	SA 5267	FL

General Provider Information

NPI Number	:	1508198078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER LYNN BLAKE SPEECH LANGUAGE PATH

Provider Business Mailing Address
First Line	:	3161 SW 50TH ST
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33312-6982
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3161 SW 50TH ST
Second Line	:
City	:	FT. LAUDERDALE
State	:	FL
Zip	:	33312
Country	:	US
Telephone Number	:	954-894-9023
Fax Number	:

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

Provider Enumeration Date	:	02/08/2010
Last Update Date	:	02/08/2010

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Directions to “ MS. JENNIFER LYNN BLAKE SPEECH LANGUAGE PATH” Practice Location

Language	Start Address	Practice Location

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