Provider Demographics
NPI:1174776140
Name:BALLIETTE, JENNIFER L (SLP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:BALLIETTE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:SENECA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:13148-1344
Mailing Address - Country:US
Mailing Address - Phone:315-651-7692
Mailing Address - Fax:315-568-2570
Practice Address - Street 1:16 RIDGE ST
Practice Address - Street 2:
Practice Address - City:SENECA FALLS
Practice Address - State:NY
Practice Address - Zip Code:13148-1344
Practice Address - Country:US
Practice Address - Phone:315-651-7692
Practice Address - Fax:315-568-2570
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-03
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018283-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY018283-1OtherNY STATE ED. DEPT.