Basic Information
| Provider Information | |||||||||
| NPI: | 1760848030 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEVENNIE | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA, CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 59 PEDEE PL | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077482319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322336327 | ||||||||
| FaxNumber: | 8647515397 | ||||||||
| Practice Location | |||||||||
| Address1: | 134 INFIELD CT | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281178026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0479968247 | ||||||||
| FaxNumber: | 7047996825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2016 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 11648 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.