Provider Demographics
NPI:1083792048
Name:THIEL, JENNIFER (MA, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:THIEL
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 1:1440 LAKESIDE AVE E
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114-1137
Mailing Address - Country:US
Mailing Address - Phone:216-692-4180
Mailing Address - Fax:216-692-4181
Practice Address - Street 1:1440 LAKESIDE AVE E
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44114-1137
Practice Address - Country:US
Practice Address - Phone:216-692-4180
Practice Address - Fax:216-692-4181
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP-8090235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1564187Medicaid
OH1564187Medicaid