Provider Demographics
NPI:1124489844
Name:GUCWA, JENELLE (CCC SLP)
Entity type:Individual
Prefix:
First Name:JENELLE
Middle Name:
Last Name:GUCWA
Suffix:
Gender:F
Credentials:CCC SLP
Other - Prefix:
Other - First Name:JENELLE
Other - Middle Name:
Other - Last Name:SHEFFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:22593 THREE NOTCH RD
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA
Mailing Address - State:MD
Mailing Address - Zip Code:20619-3054
Mailing Address - Country:US
Mailing Address - Phone:018-622-5053
Mailing Address - Fax:301-862-2548
Practice Address - Street 1:22593 THREE NOTCH RD
Practice Address - Street 2:
Practice Address - City:CALIFORNIA
Practice Address - State:MD
Practice Address - Zip Code:20619-3054
Practice Address - Country:US
Practice Address - Phone:018-622-5053
Practice Address - Fax:301-862-2548
Is Sole Proprietor?:No
Enumeration Date:2016-03-08
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110900235Z00000X
MD09344235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX486994YK00Medicare UPIN