Provider Demographics
NPI:1194932848
Name:FRY, JENNIFER CAROL (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:CAROL
Last Name:FRY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:CAROL
Other - Last Name:MCCAULEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:161 COUNTY ROAD 9951
Mailing Address - Street 2:
Mailing Address - City:GREEN FOREST
Mailing Address - State:AR
Mailing Address - Zip Code:72638-4022
Mailing Address - Country:US
Mailing Address - Phone:870-553-2284
Mailing Address - Fax:
Practice Address - Street 1:909 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GREEN FOREST
Practice Address - State:AR
Practice Address - Zip Code:72638-2316
Practice Address - Country:US
Practice Address - Phone:870-423-9246
Practice Address - Fax:877-425-4393
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR613235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR129993742Medicaid
AR119425721Medicaid