1518028141 NPI number — JENNIFER W. PUTNAM M.S. CCC-SLP

Table of content: JENNIFER W. PUTNAM M.S. CCC-SLP (NPI 1518028141)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518028141 NPI number — JENNIFER W. PUTNAM M.S. CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PUTNAM
Provider First Name:
JENNIFER
Provider Middle Name:
W.
Provider Name Prefix Text:
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518028141
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3145 DARTAGNAN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83204-5090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-520-1403
Provider Business Mailing Address Fax Number:
208-232-2766

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3145 DARTAGNAN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83204-5090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-520-1403
Provider Business Practice Location Address Fax Number:
208-232-2766
Provider Enumeration Date:
12/13/2006

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:  SLP-1405 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 12012396 . This is a "NATIONAL ASHA NUMBER" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: SLP-1405 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010145355 . This is a "REGENCE BLUE SHIELD OF ID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: SPL10 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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