Provider Demographics
NPI:1508163163
Name:JELKS, TREACIE GILL
Entity Type:Individual
Prefix:
First Name:TREACIE
Middle Name:GILL
Last Name:JELKS
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 1:2521 WEST 21 AVENUE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46404-2904
Mailing Address - Country:US
Mailing Address - Phone:219-949-6501
Mailing Address - Fax:
Practice Address - Street 1:4710 LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-2316
Practice Address - Country:US
Practice Address - Phone:708-570-1665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-17
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN29001424A2355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant