Provider Demographics
NPI:1962766634
Name:CISNEROS, JENNIFER MICHELLE (SLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:CISNEROS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 GARLAND DR
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-6238
Mailing Address - Country:US
Mailing Address - Phone:979-297-3365
Mailing Address - Fax:979-297-3541
Practice Address - Street 1:321 GARLAND DR
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-6238
Practice Address - Country:US
Practice Address - Phone:979-297-3365
Practice Address - Fax:979-297-3541
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107281235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist