Provider Demographics
NPI:1689087611
Name:DUCKWORTH, JENNIFER JANE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JANE
Last Name:DUCKWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:JANE
Other - Last Name:DIEMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:917 LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:61554-1345
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:917 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:MARQUETTE HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:61554-1345
Practice Address - Country:US
Practice Address - Phone:309-231-2772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146012121235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist