Provider Demographics
NPI:1578840153
Name:STICH-HENNEN, JESSICA RENEE (AUD, F-AAA)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:RENEE
Last Name:STICH-HENNEN
Suffix:
Gender:F
Credentials:AUD, F-AAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 N 2ND ST
Mailing Address - Street 2:SUITE #201
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6077
Mailing Address - Country:US
Mailing Address - Phone:208-489-4743
Mailing Address - Fax:208-489-4075
Practice Address - Street 1:510 N 2ND ST
Practice Address - Street 2:SUITE #201
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6077
Practice Address - Country:US
Practice Address - Phone:208-489-4743
Practice Address - Fax:208-489-4075
Is Sole Proprietor?:No
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAUD-1736231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist