Provider Demographics
NPI:1669858387
Name:LAWRENCE, JENISE (MA CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JENISE
Middle Name:
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:MISS
Other - First Name:JENISE
Other - Middle Name:
Other - Last Name:WOLFE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3640 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-3569
Mailing Address - Country:US
Mailing Address - Phone:317-920-7888
Mailing Address - Fax:
Practice Address - Street 1:3640 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-3569
Practice Address - Country:US
Practice Address - Phone:317-920-7888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22006171A235Z00000X
IN46002624A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist