Provider Demographics
NPI:1285933432
Name:MARINE, JENNIFER L (MS/CCC-SLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:MARINE
Suffix:
Gender:F
Credentials:MS/CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:276 POMMOGUSSETT RD
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01543-1403
Mailing Address - Country:US
Mailing Address - Phone:508-450-5105
Mailing Address - Fax:
Practice Address - Street 1:237 MILLBURY ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-2177
Practice Address - Country:US
Practice Address - Phone:508-755-1228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-26
Last Update Date:2011-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8180235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist