Provider Demographics
NPI:1760189625
Name:SPECCHIO, JENNA N (SLP)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:N
Last Name:SPECCHIO
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 N CENTER AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:WI
Mailing Address - Zip Code:53549-1258
Mailing Address - Country:US
Mailing Address - Phone:847-977-4228
Mailing Address - Fax:
Practice Address - Street 1:430 WILCOX ST
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1968
Practice Address - Country:US
Practice Address - Phone:920-563-5533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5490-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist