Provider Demographics
NPI:1962657791
Name:GARDNER, JENNA MARIE (MS CCC-SLP/L)
Entity type:Individual
Prefix:MISS
First Name:JENNA
Middle Name:MARIE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MS CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8266 WARBLER WAY
Mailing Address - Street 2:APT. C-11
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-1087
Mailing Address - Country:US
Mailing Address - Phone:315-383-0537
Mailing Address - Fax:
Practice Address - Street 1:301 VALLEY DR
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13207-2298
Practice Address - Country:US
Practice Address - Phone:315-468-1632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-20
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016836235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist