Provider Demographics
NPI:1114677556
Name:EDWARDS, JENNIFER MICHELLE (MS, CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 S WALL ST
Mailing Address - Street 2:
Mailing Address - City:SHAMROCK
Mailing Address - State:TX
Mailing Address - Zip Code:79079-2630
Mailing Address - Country:US
Mailing Address - Phone:806-256-2592
Mailing Address - Fax:
Practice Address - Street 1:609 15TH ST
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:TX
Practice Address - Zip Code:79095-3603
Practice Address - Country:US
Practice Address - Phone:806-447-3112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103167235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist