Provider Demographics
NPI:1730598160
Name:DAVENPORT, JANE W (CCC-SLP)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:W
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2612 PINEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-1808
Mailing Address - Country:US
Mailing Address - Phone:770-712-9832
Mailing Address - Fax:770-534-5141
Practice Address - Street 1:604 WASHINGTON ST NW STE B2
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-8545
Practice Address - Country:US
Practice Address - Phone:770-534-5141
Practice Address - Fax:770-534-5141
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP-005646235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist