Provider Demographics
NPI:1568005791
Name:WALENCIAK, JENNIFER M (SLPA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:WALENCIAK
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:HEIDLAGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1605 BLACKARD LN
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74604-3508
Mailing Address - Country:US
Mailing Address - Phone:580-304-9767
Mailing Address - Fax:
Practice Address - Street 1:1605 BLACKARD LN
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74604-3508
Practice Address - Country:US
Practice Address - Phone:580-304-9767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-21
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKSLPA1052355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant