Provider Demographics
NPI:1417252917
Name:MCFALLS, JODI L
Entity Type:Individual
Prefix:MS
First Name:JODI
Middle Name:L
Last Name:MCFALLS
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 1:5354 S FREEPORT RD
Mailing Address - Street 2:
Mailing Address - City:POLO
Mailing Address - State:IL
Mailing Address - Zip Code:61064-9748
Mailing Address - Country:US
Mailing Address - Phone:815-590-6063
Mailing Address - Fax:
Practice Address - Street 1:500 ANCHOR RD
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-8829
Practice Address - Country:US
Practice Address - Phone:815-288-6691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-14
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
IL146008250235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist