Basic Information
| Provider Information | |||||||||
| NPI: | 1922015791 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARREN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WARREN | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | SLP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1100 BLYTHE BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282035814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043554370 | ||||||||
| FaxNumber: | 7043554231 | ||||||||
| Practice Location | |||||||||
| Address1: | 10620 PARK RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282108472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046672500 | ||||||||
| FaxNumber: | 7046672507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 01/12/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 5636 | NC | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 1413V | 01 | NY | BCBS | OTHER | 7412495 | 05 | NC | MEDICAID | 92445 | 01 | NC | MEDCOST | OTHER |