Provider Demographics
NPI:1003917220
Name:WONG, GLORIA JACKEL (AU D)
Entity Type:Individual
Prefix:MS
First Name:GLORIA
Middle Name:JACKEL
Last Name:WONG
Suffix:
Gender:F
Credentials:AU D
Other - Prefix:MRS
Other - First Name:GLORIA
Other - Middle Name:BETH
Other - Last Name:JACKEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA CCCA
Mailing Address - Street 1:2900 OGDEN AVE.
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532
Mailing Address - Country:US
Mailing Address - Phone:773-248-9121
Mailing Address - Fax:773-248-9176
Practice Address - Street 1:2900 OGDEN AVE.
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532
Practice Address - Country:US
Practice Address - Phone:773-248-9121
Practice Address - Fax:773-248-9176
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147000297231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK08366Medicare ID - Type Unspecified