Provider Demographics
NPI:1548827165
Name:WILSON, JENNA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:629 STANDING ROCK RD
Mailing Address - Street 2:
Mailing Address - City:SENOIA
Mailing Address - State:GA
Mailing Address - Zip Code:30276-1405
Mailing Address - Country:US
Mailing Address - Phone:404-925-6777
Mailing Address - Fax:
Practice Address - Street 1:477 PROMINENCE CT STE 100
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-6377
Practice Address - Country:US
Practice Address - Phone:401-216-9564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-20
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP010194235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist