Provider Demographics
NPI:1083046619
Name:IRVIN, JENNIFER MAUREEN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MAUREEN
Last Name:IRVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 46
Mailing Address - Street 2:
Mailing Address - City:DAHLGREN
Mailing Address - State:IL
Mailing Address - Zip Code:62828-9715
Mailing Address - Country:US
Mailing Address - Phone:618-736-2488
Mailing Address - Fax:
Practice Address - Street 1:RR 1 BOX 46
Practice Address - Street 2:
Practice Address - City:DAHLGREN
Practice Address - State:IL
Practice Address - Zip Code:62828-9715
Practice Address - Country:US
Practice Address - Phone:618-736-2488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.005576235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist