Provider Demographics
NPI:1154546844
Name:HUMPHRIES, JENNIFER WISEMAN (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:WISEMAN
Last Name:HUMPHRIES
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 1:301 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:CALICO ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72519-0220
Mailing Address - Country:US
Mailing Address - Phone:870-297-8533
Mailing Address - Fax:
Practice Address - Street 1:301 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:CALICO ROCK
Practice Address - State:AR
Practice Address - Zip Code:72519-0220
Practice Address - Country:US
Practice Address - Phone:870-297-8533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP1245235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist