Provider Demographics
NPI:1154743433
Name:KIENZLE, JACLYN (MA, CCC, SLP)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:KIENZLE
Suffix:
Gender:F
Credentials:MA, CCC, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37208-2758
Mailing Address - Country:US
Mailing Address - Phone:219-781-1482
Mailing Address - Fax:
Practice Address - Street 1:419 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-2756
Practice Address - Country:US
Practice Address - Phone:615-348-1970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNSP 0000004299235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist