Provider Demographics
NPI:1285238998
Name:JODAR, MILDRED M (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MILDRED
Middle Name:M
Last Name:JODAR
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 HENDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-1621
Mailing Address - Country:US
Mailing Address - Phone:864-477-0272
Mailing Address - Fax:
Practice Address - Street 1:319 GARLINGTON RD STE B5
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4621
Practice Address - Country:US
Practice Address - Phone:864-417-8423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6665235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist