Provider Demographics
NPI:1326501495
Name:KENWORTHY, JESSICA BROOKE (MS CF-SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:BROOKE
Last Name:KENWORTHY
Suffix:
Gender:F
Credentials:MS CF-SLP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:RACHEL
Other - Last Name:KENWORTHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:65 SPRUCE ST APT 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-4068
Mailing Address - Country:US
Mailing Address - Phone:617-710-7108
Mailing Address - Fax:
Practice Address - Street 1:125 PRESUMPSCOT ST UNIT 10
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-5225
Practice Address - Country:US
Practice Address - Phone:207-747-5394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-07
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEST2905235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEST2905OtherSTATE OF MAINE- TEMPORARY SPEECH LANGUAGE PATHOLOGIST