MEDICARE: JACLYN KRISTENE JOHNSON CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	242.005299	IL

General Provider Information

NPI Number	:	1336753383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACLYN KRISTENE JOHNSON CCC-SLP

Provider Business Mailing Address
First Line	:	15 S THROOP ST APT 209
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-2522
Country	:	US
Telephone Number	:	608-780-2907
Fax Number	:

Provider Business Practice Location Address
First Line	:	1422 W WILLOW ST STE 101
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60642-8977
Country	:	US
Telephone Number	:	773-672-7775
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2020
Last Update Date	:	09/06/2020

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Directions to “ JACLYN KRISTENE JOHNSON CCC-SLP” Practice Location

Language	Start Address	Practice Location

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