Provider Demographics
NPI:1629456744
Name:VICK, JENNIFER (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:VICK
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14025 HUNTERS TRACE LN
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34715-6831
Mailing Address - Country:US
Mailing Address - Phone:407-234-2565
Mailing Address - Fax:
Practice Address - Street 1:14025 HUNTERS TRACE LN
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34715-6831
Practice Address - Country:US
Practice Address - Phone:407-234-2565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-08
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA15080222Q00000X, 235Z00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist