Provider Demographics
NPI:1710218029
Name:NELSON, JENNIFER (MS CCC-SLP/L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:MS CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9138 S SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-1458
Mailing Address - Country:US
Mailing Address - Phone:312-480-7152
Mailing Address - Fax:
Practice Address - Street 1:6300 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2256
Practice Address - Country:US
Practice Address - Phone:708-599-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.009747235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist