Provider Demographics
NPI:1588413611
Name:VAN DYNE, JENNIFER MASAKO
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MASAKO
Last Name:VAN DYNE
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 1:1036 SPA RD APT A
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-1180
Mailing Address - Country:US
Mailing Address - Phone:408-857-6916
Mailing Address - Fax:
Practice Address - Street 1:1419 FOREST DR STE 206
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21403-1473
Practice Address - Country:US
Practice Address - Phone:410-280-9788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist