Provider Demographics
NPI:1528735628
Name:BONVENCA, JESSICA ASHLEY
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ASHLEY
Last Name:BONVENCA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 VILLA DI ESTE TER UNIT 208
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-1633
Mailing Address - Country:US
Mailing Address - Phone:732-299-1720
Mailing Address - Fax:
Practice Address - Street 1:138 VILLA DI ESTE TER UNIT 208
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-1633
Practice Address - Country:US
Practice Address - Phone:732-299-1720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00978300235Z00000X
FLSA18018235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist