Provider Demographics
NPI:1811221351
Name:FORMEA, JESSICA LYNNE (MS, CFY-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LYNNE
Last Name:FORMEA
Suffix:
Gender:F
Credentials:MS, CFY-SLP
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:LYNNE
Other - Last Name:KEPNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:905 E GENEVA ST
Mailing Address - Street 2:
Mailing Address - City:DELAVAN
Mailing Address - State:WI
Mailing Address - Zip Code:53115-1922
Mailing Address - Country:US
Mailing Address - Phone:262-728-6319
Mailing Address - Fax:
Practice Address - Street 1:905 E GENEVA ST
Practice Address - Street 2:
Practice Address - City:DELAVAN
Practice Address - State:WI
Practice Address - Zip Code:53115-1922
Practice Address - Country:US
Practice Address - Phone:262-728-6319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3287-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist