Provider Demographics
NPI:1699068650
Name:MALLIN, JENNIFER S (CCC-SLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:MALLIN
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 1:119 MAIDEN LN
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-4101
Mailing Address - Country:US
Mailing Address - Phone:201-384-1154
Mailing Address - Fax:
Practice Address - Street 1:119 MAIDEN LN
Practice Address - Street 2:
Practice Address - City:BERGENFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07621-4101
Practice Address - Country:US
Practice Address - Phone:201-384-1154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00663600235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist