Provider Demographics
NPI:1699915256
Name:BODURTHA, JENNA
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:BODURTHA
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 1:3687 POST RD
Mailing Address - Street 2:APT #50
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-8737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:213 ROBINSON ST
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-3590
Practice Address - Country:US
Practice Address - Phone:401-284-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RISP00172-P235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist