Provider Demographics
NPI:1154556389
Name:JINES, JENNIFER NICOLE (MA CCC SLP)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:NICOLE
Last Name:JINES
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:500 W GRANT ST APT C
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MO
Mailing Address - Zip Code:63841-2451
Mailing Address - Country:US
Mailing Address - Phone:573-471-2686
Mailing Address - Fax:573-471-3515
Practice Address - Street 1:20794 US HIGHWAY 61
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-7260
Practice Address - Country:US
Practice Address - Phone:573-471-2686
Practice Address - Fax:573-471-3515
Is Sole Proprietor?:No
Enumeration Date:2009-05-18
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000159411235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist