Provider Demographics
NPI:1477135705
Name:REIS, JENNA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:REIS
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5813 GUINEVERE LN
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583-5652
Mailing Address - Country:US
Mailing Address - Phone:567-356-0147
Mailing Address - Fax:
Practice Address - Street 1:4624 SUMMERDALE DR
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-1368
Practice Address - Country:US
Practice Address - Phone:850-994-3456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-26
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA19640235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist