Provider Demographics
NPI:1700432424
Name:SULLIVAN, JACLYN ANN
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:ANN
Last Name:SULLIVAN
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 1:12910 S LA GRANGE RD
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-1717
Mailing Address - Country:US
Mailing Address - Phone:708-448-1234
Mailing Address - Fax:
Practice Address - Street 1:12910 S LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:PALOS PARK
Practice Address - State:IL
Practice Address - Zip Code:60464-1717
Practice Address - Country:US
Practice Address - Phone:708-448-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-18
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2676237700000X
IL146.011457235Z00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist