Healthcare Provider Details

I. General information

NPI: 1629519749
Provider Name (Legal Business Name): JENNIFER MORENO M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2017
Last Update Date: 12/22/2023
Certification Date: 12/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8004 WEST AVE
SAN ANTONIO TX
78213-1870
US

IV. Provider business mailing address

1220 N MALINCHE AVE
LAREDO TX
78043-3354
US

V. Phone/Fax

Practice location:
  • Phone: 210-340-2627
  • Fax:
Mailing address:
  • Phone: 956-722-2431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number38415
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number120385
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: