Provider Demographics
NPI:1962522417
Name:STEVENS, JENNIFER JO (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JO
Last Name:STEVENS
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 1:820 COUNTRYSIDE LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-8906
Mailing Address - Country:US
Mailing Address - Phone:812-343-1823
Mailing Address - Fax:812-342-0657
Practice Address - Street 1:820 COUNTRYSIDE LN
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-8906
Practice Address - Country:US
Practice Address - Phone:812-343-1823
Practice Address - Fax:812-342-0657
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22003025A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN22003025AOtherSTATE LICENSE NUMBER
IN200618760Medicaid