Provider Demographics
NPI:1013573153
Name:SHOCKLEY, JANE ELISE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:ELISE
Last Name:SHOCKLEY
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 STRATFORD CT
Mailing Address - Street 2:
Mailing Address - City:INDIAN HEAD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60525-4456
Mailing Address - Country:US
Mailing Address - Phone:630-915-4012
Mailing Address - Fax:
Practice Address - Street 1:7801 W 75TH ST
Practice Address - Street 2:
Practice Address - City:BRIDGEVIEW
Practice Address - State:IL
Practice Address - Zip Code:60455-1288
Practice Address - Country:US
Practice Address - Phone:708-496-8722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01110196OtherASHA