Provider Demographics
NPI:1780304428
Name:WOLLERMAN, JENNA MICHELE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:MICHELE
Last Name:WOLLERMAN
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 1:40 SOMERSET CT
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-1768
Mailing Address - Country:US
Mailing Address - Phone:201-937-1476
Mailing Address - Fax:
Practice Address - Street 1:311 COOPER ROAD
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017
Practice Address - Country:US
Practice Address - Phone:678-205-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP012265235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist