Provider Demographics
NPI:1720592470
Name:LEWIS, JENNIFER (MA, CCC/SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LEWIS
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 1:7260 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-9354
Mailing Address - Country:US
Mailing Address - Phone:815-469-4330
Mailing Address - Fax:
Practice Address - Street 1:7260 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-9354
Practice Address - Country:US
Practice Address - Phone:815-469-4330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-16
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146004600235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist