Provider Demographics
NPI:1366809477
Name:WIDENER, JENNIFER MARIE (MCD, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:WIDENER
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 STONERIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CATAULA
Mailing Address - State:GA
Mailing Address - Zip Code:31804-2130
Mailing Address - Country:US
Mailing Address - Phone:229-224-6826
Mailing Address - Fax:
Practice Address - Street 1:1720 KNOWLES RD
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36869-7135
Practice Address - Country:US
Practice Address - Phone:334-291-0485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3296235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist