Provider Demographics
NPI:1255986212
Name:WIEDERHOLD, JENNA KATE
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:KATE
Last Name:WIEDERHOLD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 1ST ST NE APT 906
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-4866
Mailing Address - Country:US
Mailing Address - Phone:704-774-0696
Mailing Address - Fax:
Practice Address - Street 1:1160 1ST ST NE APT 906
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-4866
Practice Address - Country:US
Practice Address - Phone:704-774-0696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist