MEDICARE: JESSICA PENICK MS, CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	3151	NM

General Provider Information

NPI Number	:	1548399967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA PENICK MS, CCC-SLP

Provider Business Mailing Address
First Line	:	7200 MONTGOMERY BLVD NE # 194
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87109-1510
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7108 GLADDEN AVE NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-1464
Country	:	US
Telephone Number	:	505-238-6106
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2007
Last Update Date	:	07/08/2007

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