Provider Demographics
NPI:1073868626
Name:SHANNON, JACQUELYN MARIE (MS SLP)
Entity Type:Individual
Prefix:MISS
First Name:JACQUELYN
Middle Name:MARIE
Last Name:SHANNON
Suffix:
Gender:F
Credentials:MS SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1049 E WILSON ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510-2474
Mailing Address - Country:US
Mailing Address - Phone:630-715-0199
Mailing Address - Fax:
Practice Address - Street 1:1049 E WILSON ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510-2474
Practice Address - Country:US
Practice Address - Phone:630-715-0199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242002313235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist