Provider Demographics
NPI:1821645334
Name:SIMISON, JENNY ROCHELLE
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:ROCHELLE
Last Name:SIMISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:ROCHELLE
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:245 N 3RD E
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-2734
Mailing Address - Country:US
Mailing Address - Phone:208-587-8255
Mailing Address - Fax:
Practice Address - Street 1:245 N 3RD E
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-2734
Practice Address - Country:US
Practice Address - Phone:208-587-8255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist