1194932848 NPI number — MRS. JENNIFER CAROL FRY M.S., CCC-SLP

Table of content: MRS. JENNIFER CAROL FRY M.S., CCC-SLP (NPI 1194932848)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194932848 NPI number — MRS. JENNIFER CAROL FRY M.S., CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRY
Provider First Name:
JENNIFER
Provider Middle Name:
CAROL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.S., CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCCAULEY
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
CAROL
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194932848
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
161 COUNTY ROAD 9951
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREEN FOREST
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72638-4022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-553-2284
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
909 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREEN FOREST
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72638-2316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-423-9246
Provider Business Practice Location Address Fax Number:
877-425-4393
Provider Enumeration Date:
05/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  613 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 129993742 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 119425721 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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