Provider Demographics
NPI:1700480415
Name:WATNICK, JENNA BETH (MS/CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:BETH
Last Name:WATNICK
Suffix:
Gender:F
Credentials:MS/CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01904-3230
Mailing Address - Country:US
Mailing Address - Phone:781-593-2727
Mailing Address - Fax:
Practice Address - Street 1:176 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01904-3230
Practice Address - Country:US
Practice Address - Phone:781-593-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8346235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1922174226Medicaid
MA19221174226Medicaid