Provider Demographics
NPI:1760872139
Name:WALLEN, JENNIFER NICOLE (HIS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:WALLEN
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 SHUMAN BLVD
Mailing Address - Street 2:STE. 401
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-8458
Mailing Address - Country:US
Mailing Address - Phone:630-303-5380
Mailing Address - Fax:978-313-6824
Practice Address - Street 1:1722 DEL PRADO BLVD S
Practice Address - Street 2:STE 2
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-5525
Practice Address - Country:US
Practice Address - Phone:239-458-7900
Practice Address - Fax:239-458-9977
Is Sole Proprietor?:No
Enumeration Date:2015-01-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAS5065OtherHIS LICENSE