Provider Demographics
NPI:1548548357
Name:SANDY, JENELLE HELENE EZCURRA (AUD)
Entity type:Individual
Prefix:
First Name:JENELLE
Middle Name:HELENE EZCURRA
Last Name:SANDY
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1285 APACHE AVE # 306
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96155-7672
Mailing Address - Country:US
Mailing Address - Phone:530-318-4010
Mailing Address - Fax:
Practice Address - Street 1:2074 LAKE TAHOE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-6407
Practice Address - Country:US
Practice Address - Phone:530-318-4010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-27
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147001386231H00000X
NVA3154231H00000X
CAAU3526231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist