Provider Demographics
NPI:1942652300
Name:DONAHUE, JACLYN
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:DONAHUE
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 1:1737 N PAULINA ST APT 103
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1462
Mailing Address - Country:US
Mailing Address - Phone:847-363-2371
Mailing Address - Fax:
Practice Address - Street 1:6501 S PROMONTORY DR # 1003
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-1002
Practice Address - Country:US
Practice Address - Phone:773-363-6700
Practice Address - Fax:888-765-4321
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146013776235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist