Provider Demographics
NPI:1306091665
Name:TAVAREZ, JENNIFER (SLP MA CCC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:TAVAREZ
Suffix:
Gender:F
Credentials:SLP MA CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 LAKE RICONDA DR
Mailing Address - Street 2:
Mailing Address - City:RINGWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07456-1303
Mailing Address - Country:US
Mailing Address - Phone:917-526-9430
Mailing Address - Fax:
Practice Address - Street 1:622 TRAFALGAR CT
Practice Address - Street 2:
Practice Address - City:DANIA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33004-5412
Practice Address - Country:US
Practice Address - Phone:917-526-9430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015235-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist