Provider Demographics
NPI:1053925115
Name:KHAYUMOV, JENNIFER (MA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KHAYUMOV
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19831 51ST AVE
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-1341
Mailing Address - Country:US
Mailing Address - Phone:718-530-5413
Mailing Address - Fax:
Practice Address - Street 1:15220 11TH AVE
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-1999
Practice Address - Country:US
Practice Address - Phone:718-767-8810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030022-01235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist