Provider Demographics
NPI:1346584950
Name:MENNELLA, JESSICA M (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:MENNELLA
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 1:24 WOODLAND RD
Mailing Address - Street 2:
Mailing Address - City:JAMESBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08831-1344
Mailing Address - Country:US
Mailing Address - Phone:732-501-8120
Mailing Address - Fax:
Practice Address - Street 1:24 WOODLAND RD
Practice Address - Street 2:
Practice Address - City:JAMESBURG
Practice Address - State:NJ
Practice Address - Zip Code:08831-1344
Practice Address - Country:US
Practice Address - Phone:732-501-8120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00436100235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist