Provider Demographics
NPI:1689764177
Name:HEINISCH, JENNIFER MARIE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:HEINISCH
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8800 S ROOD RD
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60145-8288
Mailing Address - Country:US
Mailing Address - Phone:815-784-5733
Mailing Address - Fax:
Practice Address - Street 1:1 LUCINDA AVE.
Practice Address - Street 2:NIU SPEECH-LANGUAGE HEARING CLINIC
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-2899
Practice Address - Country:US
Practice Address - Phone:815-753-1481
Practice Address - Fax:815-753-1664
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist