Provider Demographics
NPI:1700279569
Name:STUPKA, JEANNINE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:
Last Name:STUPKA
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 1:5002 MAIN ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-3659
Mailing Address - Country:US
Mailing Address - Phone:630-929-0122
Mailing Address - Fax:
Practice Address - Street 1:5002 MAIN ST
Practice Address - Street 2:SUITE 4
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-3659
Practice Address - Country:US
Practice Address - Phone:630-929-0122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-17
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.012547235Z00000X
CASP 19031235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist