Provider Demographics
NPI:1093094765
Name:WENCK, JESSICA ANN CIRILLO (MA-CCC- SLP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ANN CIRILLO
Last Name:WENCK
Suffix:
Gender:F
Credentials:MA-CCC- SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:222 ROOSEVELT AVE APT 10
Mailing Address - Street 2:
Mailing Address - City:HORSEHEADS
Mailing Address - State:NY
Mailing Address - Zip Code:14845-8233
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:309 W THURSTON ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-1124
Practice Address - Country:US
Practice Address - Phone:607-735-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY58021265235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist