Provider Demographics
NPI:1285001768
Name:DZIEDZIC, JENNIFER LAUREN (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LAUREN
Last Name:DZIEDZIC
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LAUREN
Other - Last Name:VAMOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:5711 FULLGARDEN CT
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77449-2635
Mailing Address - Country:US
Mailing Address - Phone:305-335-2330
Mailing Address - Fax:
Practice Address - Street 1:5711 FULLGARDEN CT
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449-2635
Practice Address - Country:US
Practice Address - Phone:305-335-2330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
TX114902235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1285001768Medicaid