Provider Demographics
NPI:1497232821
Name:WRINKLE, JESSICA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WRINKLE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:MCNULTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15820 ADDISON RD
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3549
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:413 GEORGE HOPPER RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-5519
Practice Address - Country:US
Practice Address - Phone:469-667-2617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-28
Last Update Date:2018-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105802235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist