Provider Demographics
NPI:1801053301
Name:MAGENNIS, JACQUELINE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MAGENNIS
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 1:1126 S 70TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-3151
Mailing Address - Country:US
Mailing Address - Phone:414-456-2331
Mailing Address - Fax:414-456-2339
Practice Address - Street 1:1126 S 70TH ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-3151
Practice Address - Country:US
Practice Address - Phone:414-456-2331
Practice Address - Fax:414-456-2339
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2354-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist