Provider Demographics
NPI:1275662728
Name:DALE, JACI RAE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JACI
Middle Name:RAE
Last Name:DALE
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 1:701 S LEDFORD ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946-2532
Mailing Address - Country:US
Mailing Address - Phone:618-253-7019
Mailing Address - Fax:
Practice Address - Street 1:701 S LEDFORD ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-2532
Practice Address - Country:US
Practice Address - Phone:618-253-7019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist