Provider Demographics
NPI:1790994515
Name:NOLDEN, JEWEL DEAN
Entity Type:Individual
Prefix:
First Name:JEWEL
Middle Name:DEAN
Last Name:NOLDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2239 S 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60155-3939
Mailing Address - Country:US
Mailing Address - Phone:312-304-1254
Mailing Address - Fax:
Practice Address - Street 1:2239 S 19TH AVE
Practice Address - Street 2:
Practice Address - City:BROADVIEW
Practice Address - State:IL
Practice Address - Zip Code:60155-3939
Practice Address - Country:US
Practice Address - Phone:312-304-1254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILJN79311200P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist