Provider Demographics
NPI:1518187871
Name:ENNIS, JENNIFER LYNN (MCD CCC SLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:ENNIS
Suffix:
Gender:F
Credentials:MCD CCC SLP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:FALLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:858 HIGHWAY F
Mailing Address - Street 2:
Mailing Address - City:HARVIELL
Mailing Address - State:MO
Mailing Address - Zip Code:63945-8126
Mailing Address - Country:US
Mailing Address - Phone:573-224-3916
Mailing Address - Fax:573-224-3412
Practice Address - Street 1:127 WALNUT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MO
Practice Address - Zip Code:63944-0320
Practice Address - Country:US
Practice Address - Phone:573-224-3916
Practice Address - Fax:573-224-3412
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004029091235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO467340808Medicaid