Provider Demographics
NPI:1629501028
Name:FRICKE, JESSICA (MACCC-SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FRICKE
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2412 OLD STATE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-6251
Mailing Address - Country:US
Mailing Address - Phone:217-371-2250
Mailing Address - Fax:
Practice Address - Street 1:2412 OLD STATE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-6251
Practice Address - Country:US
Practice Address - Phone:217-371-2250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146011638235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist