Basic Information
| Provider Information | |||||||||
| NPI: | 1164728796 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLANE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1042 ARROWHEAD DR | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463111969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197430256 | ||||||||
| FaxNumber: | 2193907549 | ||||||||
| Practice Location | |||||||||
| Address1: | 10915 W 133RD AVE | ||||||||
| Address2: | |||||||||
| City: | CEDAR LAKE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463039706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193907498 | ||||||||
| FaxNumber: | 2193907549 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2011 | ||||||||
| LastUpdateDate: | 12/26/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.