Provider Demographics
NPI:1982870770
Name:JENN, REBECCA L
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:JENN
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 1:1821 S STOUGHTON RD
Mailing Address - Street 2:DEAN MEDICAL CENTER
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53716-2257
Mailing Address - Country:US
Mailing Address - Phone:608-260-6000
Mailing Address - Fax:
Practice Address - Street 1:1821 S STOUGHTON RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53716-2257
Practice Address - Country:US
Practice Address - Phone:608-260-6000
Practice Address - Fax:608-260-6906
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-01
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1231-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42734300Medicaid
WI42734300Medicaid