Provider Demographics
NPI:1770842031
Name:SMITH, JENNIFER MARTA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARTA
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:LOGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1340 BRADDOCK PL
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-1693
Mailing Address - Country:US
Mailing Address - Phone:301-619-8139
Mailing Address - Fax:
Practice Address - Street 1:1340 BRADDOCK PL
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-1693
Practice Address - Country:US
Practice Address - Phone:301-619-8139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-08
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202008911235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist