Provider Demographics
NPI:1023304342
Name:CONNELL, JODI EDKINS (MS ED CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JODI
Middle Name:EDKINS
Last Name:CONNELL
Suffix:
Gender:F
Credentials:MS ED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 DELIA TRL
Mailing Address - Street 2:
Mailing Address - City:RUSH
Mailing Address - State:NY
Mailing Address - Zip Code:14543-9437
Mailing Address - Country:US
Mailing Address - Phone:585-533-9030
Mailing Address - Fax:
Practice Address - Street 1:85 SHELL EDGE DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-4356
Practice Address - Country:US
Practice Address - Phone:585-359-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-24
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008202-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01497492Medicaid