Provider Demographics
NPI:1871759753
Name:JENKINS, STACIE MARIE (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:MARIE
Last Name:JENKINS
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 AMANA PL
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-3049
Mailing Address - Country:US
Mailing Address - Phone:716-828-7426
Mailing Address - Fax:
Practice Address - Street 1:51 SAINT JOHNS PARKSIDE ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14210-2515
Practice Address - Country:US
Practice Address - Phone:716-828-9467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist