Provider Demographics
NPI:1679755565
Name:MICYK, JENNIFER L (MS, CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:MICYK
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:BOLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC/SLP
Mailing Address - Street 1:1201 W 38TH ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 W 38TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1006
Practice Address - Country:US
Practice Address - Phone:512-406-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102107235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist