Provider Demographics
NPI:1104067206
Name:EDWARDS-MAYES, JENNIFER CHRISTINE (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CHRISTINE
Last Name:EDWARDS-MAYES
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8245 HOLLY RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2443
Mailing Address - Country:US
Mailing Address - Phone:810-603-0040
Mailing Address - Fax:810-603-0044
Practice Address - Street 1:8245 HOLLY RD
Practice Address - Street 2:SUITE 204
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439
Practice Address - Country:US
Practice Address - Phone:810-603-0040
Practice Address - Fax:810-603-0044
Is Sole Proprietor?:No
Enumeration Date:2009-03-19
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
MI12031896235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI12031896OtherASHA ID NUMBER