Provider Demographics
NPI:1255406005
Name:WENZL, JESSICA ROSE (MA CCCSLP)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ROSE
Last Name:WENZL
Suffix:
Gender:F
Credentials:MA CCCSLP
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:ROSE
Other - Last Name:CROSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5523 SE GLADSTONE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-3971
Mailing Address - Country:US
Mailing Address - Phone:503-490-0579
Mailing Address - Fax:
Practice Address - Street 1:17727 E BURNSIDE ST
Practice Address - Street 2:SUITE B
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-4803
Practice Address - Country:US
Practice Address - Phone:503-215-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13215235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0663623OtherTRIWEST
CAGSP000390Medicaid
CAGSP000390Medicaid