Provider Demographics
NPI:1235119538
Name:JONES-FASSETT, MICHELE K (AUD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:K
Last Name:JONES-FASSETT
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:K
Other - Last Name:IHNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:698 FEATHERSTONE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6303
Mailing Address - Country:US
Mailing Address - Phone:815-398-3277
Mailing Address - Fax:815-484-7001
Practice Address - Street 1:698 FEATHERSTONE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6303
Practice Address - Country:US
Practice Address - Phone:815-398-3277
Practice Address - Fax:815-484-7001
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147000937231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL147000937Medicaid
ILP06969Medicare UPIN
ILK45228Medicare PIN