Provider Demographics
NPI:1154578102
Name:FOSTER, JEAN ROSE (MCD, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:ROSE
Last Name:FOSTER
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4615 PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-8637
Mailing Address - Country:US
Mailing Address - Phone:870-972-5600
Mailing Address - Fax:
Practice Address - Street 1:4208 CHIEFTAN LN
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7655
Practice Address - Country:US
Practice Address - Phone:870-910-7819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-21
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#1778235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARSP#1778Medicaid