Provider Demographics
NPI:1316448228
Name:STARK, JENNIFER LYNN (MA CCC-SLP, CBIS)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:STARK
Suffix:
Gender:F
Credentials:MA CCC-SLP, CBIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8988 TAVISTOCK CT
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:32715 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MI
Practice Address - Zip Code:48336-3113
Practice Address - Country:US
Practice Address - Phone:248-427-1310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty