Provider Demographics
NPI:1548772270
Name:TOLLEY, JENNIFER LEA
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LEA
Last Name:TOLLEY
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 1:409 W DALE
Mailing Address - Street 2:
Mailing Address - City:DAHLGREN
Mailing Address - State:IL
Mailing Address - Zip Code:62828
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:409 WEST DALE STREET
Practice Address - Street 2:
Practice Address - City:DAHLGREN
Practice Address - State:IL
Practice Address - Zip Code:62810
Practice Address - Country:US
Practice Address - Phone:618-736-2316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-03
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist