Provider Demographics
NPI:1215397096
Name:LIZAMA, JENNA MARIE (SLP-A)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:LIZAMA
Suffix:
Gender:F
Credentials:SLP-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23314 N HONCHO CT
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85373-5000
Mailing Address - Country:US
Mailing Address - Phone:602-309-8845
Mailing Address - Fax:
Practice Address - Street 1:23314 N HONCHO CT
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85373-5000
Practice Address - Country:US
Practice Address - Phone:602-309-8845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA77462355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant