Provider Demographics
NPI:1891346599
Name:GILLEN, JENNA LEE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:JENNA
Middle Name:LEE
Last Name:GILLEN
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 1:1008 N MADISON ST
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-3418
Mailing Address - Country:US
Mailing Address - Phone:315-271-7150
Mailing Address - Fax:
Practice Address - Street 1:400 LAKE ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-2132
Practice Address - Country:US
Practice Address - Phone:607-274-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029146235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
14105406OtherAMERICAN SPEECH-LANGUAGE-HEARING ASSOCIATION