Provider Demographics
NPI:1144623976
Name:ILCONICH, JENNIFER (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:ILCONICH
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 VALLEYCREST DR
Mailing Address - Street 2:
Mailing Address - City:CECIL
Mailing Address - State:PA
Mailing Address - Zip Code:15321-1138
Mailing Address - Country:US
Mailing Address - Phone:419-787-8678
Mailing Address - Fax:
Practice Address - Street 1:146 VALLEYCREST DR
Practice Address - Street 2:
Practice Address - City:CECIL
Practice Address - State:PA
Practice Address - Zip Code:15321-1138
Practice Address - Country:US
Practice Address - Phone:419-787-8678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL008386235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist