Provider Demographics
NPI:1548717176
Name:FENCEL, JESSICA ATICK
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ATICK
Last Name:FENCEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7231 SW 123RD PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33183
Mailing Address - Country:US
Mailing Address - Phone:786-429-3619
Mailing Address - Fax:
Practice Address - Street 1:12030 SW 129TH CT
Practice Address - Street 2:SUITE # 209
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4584
Practice Address - Country:US
Practice Address - Phone:786-429-3619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ7799235Z00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program