Provider Demographics
NPI:1235574310
Name:WILES, JENNIFER MARIAN (MS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIAN
Last Name:WILES
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MARIAN
Other - Last Name:WILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:112 HEATHERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-4889
Mailing Address - Country:US
Mailing Address - Phone:309-360-0707
Mailing Address - Fax:
Practice Address - Street 1:112 HEATHERVIEW DR
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-4889
Practice Address - Country:US
Practice Address - Phone:309-360-0707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.011134235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist