Provider Demographics
NPI:1447911557
Name:BENNETT, JORDAN (CCC- SLP)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:CCC- SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 PARK PLACE AVE
Mailing Address - Street 2:
Mailing Address - City:BRADLEY BEACH
Mailing Address - State:NJ
Mailing Address - Zip Code:07720-1436
Mailing Address - Country:US
Mailing Address - Phone:610-529-9322
Mailing Address - Fax:
Practice Address - Street 1:766 BROAD ST
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:NJ
Practice Address - Zip Code:07702-4203
Practice Address - Country:US
Practice Address - Phone:855-428-8246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-02
Last Update Date:2022-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS01086700235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty