Provider Demographics
NPI:1942598867
Name:WILDE, JANA SUE (MS,CCC,SLP)
Entity Type:Individual
Prefix:MRS
First Name:JANA
Middle Name:SUE
Last Name:WILDE
Suffix:
Gender:F
Credentials:MS,CCC,SLP
Other - Prefix:MRS
Other - First Name:JANA
Other - Middle Name:SUE
Other - Last Name:SIMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS,CCC/SLP
Mailing Address - Street 1:5610 TOWN CENTER DR
Mailing Address - Street 2:APT. # 14
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-4419
Mailing Address - Country:US
Mailing Address - Phone:630-915-5936
Mailing Address - Fax:
Practice Address - Street 1:5610 TOWN CENTER DR
Practice Address - Street 2:APT. # 14
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-4419
Practice Address - Country:US
Practice Address - Phone:630-915-5936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-12
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004409A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist