Provider Demographics
NPI:1215470075
Name:REGAN, JENNA MARIE
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:REGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10460 QUEENS BLVD APT 3K
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-7320
Mailing Address - Country:US
Mailing Address - Phone:914-262-1250
Mailing Address - Fax:
Practice Address - Street 1:10460 QUEENS BLVD APT 3K
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7320
Practice Address - Country:US
Practice Address - Phone:914-262-1250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-28
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023286-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist