Provider Demographics
NPI:1720477987
Name:WILSON, JENNIFER (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WILSON
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 1:400 S MOONLIGHT RD
Mailing Address - Street 2:12J
Mailing Address - City:GARDNER
Mailing Address - State:KS
Mailing Address - Zip Code:66030-2502
Mailing Address - Country:US
Mailing Address - Phone:913-594-2738
Mailing Address - Fax:
Practice Address - Street 1:400 S MOONLIGHT RD
Practice Address - Street 2:12J
Practice Address - City:GARDNER
Practice Address - State:KS
Practice Address - Zip Code:66030-2502
Practice Address - Country:US
Practice Address - Phone:913-594-2738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2809235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist