Basic Information
| Provider Information | |||||||||
| NPI: | 1669858387 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAWRENCE | ||||||||
| FirstName: | JENISE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A. CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WOLFE | ||||||||
| OtherFirstName: | JENISE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3640 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462053569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179207888 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3640 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462053569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179207888 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2015 | ||||||||
| LastUpdateDate: | 08/04/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 22006171A | IN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 46002624A | IN | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.