Basic Information
Provider Information | |||||||||
NPI: | 1992008148 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JURGENS | ||||||||
FirstName: | BRITTANY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.A., CCC-SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NOLAN | ||||||||
OtherFirstName: | BRITTANY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5626 MELBURY CT | ||||||||
Address2: |   | ||||||||
City: | MASON | ||||||||
State: | OH | ||||||||
PostalCode: | 450407890 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5132260878 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 7591 TYLERS PLACE BLVD | ||||||||
Address2: |   | ||||||||
City: | WEST CHESTER | ||||||||
State: | OH | ||||||||
PostalCode: | 450696308 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5137556600 | ||||||||
FaxNumber: | 5137553762 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/09/2010 | ||||||||
LastUpdateDate: | 09/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2355S0801X | 242.001622 | IL | N |   | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant | 235Z00000X | SP.13718 | OH | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
ID Information
ID | Type | State | Issuer | Description | 0406425 | 05 | OH |   | MEDICAID |