Provider Demographics
NPI:1154581767
Name:HARSELL, JENNA MARIE (MS CCC- SLP)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:HARSELL
Suffix:
Gender:F
Credentials:MS CCC- SLP
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:MARIE
Other - Last Name:BUCKNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24803 STATE HIGHWAY Z
Mailing Address - Street 2:
Mailing Address - City:EWING
Mailing Address - State:MO
Mailing Address - Zip Code:63440-2142
Mailing Address - Country:US
Mailing Address - Phone:573-822-8511
Mailing Address - Fax:
Practice Address - Street 1:3801 MEADOW DR
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-5941
Practice Address - Country:US
Practice Address - Phone:217-316-6683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146008926235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist