Provider Demographics
NPI:1952420713
Name:JEROME, CALLIE L (MA, CCC SLP)
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:L
Last Name:JEROME
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:PO BOX 172
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:WI
Mailing Address - Zip Code:53939-0172
Mailing Address - Country:US
Mailing Address - Phone:920-394-2010
Mailing Address - Fax:608-297-9328
Practice Address - Street 1:251 FOREST LN
Practice Address - Street 2:
Practice Address - City:MONTELLO
Practice Address - State:WI
Practice Address - Zip Code:53949-9380
Practice Address - Country:US
Practice Address - Phone:608-297-2153
Practice Address - Fax:608-297-9328
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2691154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42576800Medicaid