MEDICARE: MRS. JENNIFER L JACKSON-LAURENT M.A. 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		IL

General Provider Information

NPI Number	:	1922124601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER L JACKSON-LAURENT M.A. CCC-SLP

Provider Business Mailing Address
First Line	:	3558 S KING DR
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653-1110
Country	:	US
Telephone Number	:	773-865-3558
Fax Number	:	312-326-4149

Provider Business Practice Location Address
First Line	:	3558 S KING DR.
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653-1110
Country	:	US
Telephone Number	:	773-865-3558
Fax Number	:	312-326-4149

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

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	07/08/2007

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