Provider Demographics
NPI:1508534876
Name:LAWRENCE, JENNELLA ELIZABETH (MA)
Entity Type:Individual
Prefix:
First Name:JENNELLA
Middle Name:ELIZABETH
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:JENNELLA
Other - Middle Name:ELIZABETH
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15485 SARATOGA DR
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34604-0727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20158 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-3832
Practice Address - Country:US
Practice Address - Phone:352-796-0069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA20719235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist