Provider Demographics
NPI:1700362217
Name:NILES, JENNA MARIE TELLERICO (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JENNA
Middle Name:MARIE TELLERICO
Last Name:NILES
Suffix:
Gender:F
Credentials:MS 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:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-0421
Mailing Address - Country:US
Mailing Address - Phone:860-284-9779
Mailing Address - Fax:860-409-2190
Practice Address - Street 1:30 AVON MEADOW LN
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3745
Practice Address - Country:US
Practice Address - Phone:860-284-9779
Practice Address - Fax:860-409-2190
Is Sole Proprietor?:No
Enumeration Date:2018-07-17
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5633235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist