Provider Demographics
NPI:1801365754
Name:KAIDE LYNN JACKSTADT
Entity type:Organization
Organization Name:KAIDE LYNN JACKSTADT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SLP/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAIDE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSTADT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-420-3999
Mailing Address - Street 1:189 E US HIGHWAY 40 STE D
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:IL
Mailing Address - Zip Code:62294-2267
Mailing Address - Country:US
Mailing Address - Phone:618-420-3999
Mailing Address - Fax:
Practice Address - Street 1:189 E US HIGHWAY 40 STE D
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:IL
Practice Address - Zip Code:62294-2267
Practice Address - Country:US
Practice Address - Phone:618-420-3999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-21
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty