Provider Demographics
NPI:1699896563
Name:RICHARD, JENNIFER LEIGH (MA CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LEIGH
Last Name:RICHARD
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:873 GRAND REGENCY POINTE
Mailing Address - Street 2:APT #105
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-3586
Mailing Address - Country:US
Mailing Address - Phone:321-279-8690
Mailing Address - Fax:
Practice Address - Street 1:873 GRANDE REGENCY POINTE
Practice Address - Street 2:APARTMENT 105
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-9147
Practice Address - Country:US
Practice Address - Phone:321-279-8690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7107235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891995000Medicaid