Provider Demographics
NPI:1689968398
Name:BLAINE, JENNIFER N (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:N
Last Name:BLAINE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:N
Other - Last Name:NUSIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10 ARPAD ST
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-2203
Mailing Address - Country:US
Mailing Address - Phone:516-672-3462
Mailing Address - Fax:
Practice Address - Street 1:10 ARPAD ST
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-2203
Practice Address - Country:US
Practice Address - Phone:516-672-3462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-31
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020997235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist