Provider Demographics
NPI:1578684130
Name:KIENZLE, JEAN A (SLP)
Entity type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:A
Last Name:KIENZLE
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 1:13037 RHODE ST
Mailing Address - Street 2:
Mailing Address - City:CEDAR LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46303-9745
Mailing Address - Country:US
Mailing Address - Phone:219-374-5051
Mailing Address - Fax:
Practice Address - Street 1:6775 PROSPERI DR
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-4789
Practice Address - Country:US
Practice Address - Phone:708-429-1260
Practice Address - Fax:708-429-6622
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist