Provider Demographics
NPI:1619673241
Name:BAUER, JENNIFER (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BAUER
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 1:1802 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1355
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:203 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKTON
Practice Address - State:IL
Practice Address - Zip Code:61072-2418
Practice Address - Country:US
Practice Address - Phone:815-957-0099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242006557235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist