Provider Demographics
NPI:1578301206
Name:JEBB, KONNER
Entity type:Individual
Prefix:
First Name:KONNER
Middle Name:
Last Name:JEBB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KASSAUNDRA
Other - Middle Name:
Other - Last Name:JEBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:76 NORTHEASTERN BLVD UNIT 40
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03062-3174
Mailing Address - Country:US
Mailing Address - Phone:603-882-4500
Mailing Address - Fax:
Practice Address - Street 1:76 NORTHEASTERN BLVD UNIT 40
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03062-3174
Practice Address - Country:US
Practice Address - Phone:603-882-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3246235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty