Healthcare Provider Details

I. General information

NPI: 1932877875
Provider Name (Legal Business Name): IVONNE JAZMIN GUZMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2021
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1957 W DICKENS AVE
CHICAGO IL
60614-3934
US

IV. Provider business mailing address

1301 W COSSITT AVE
LA GRANGE IL
60525-2145
US

V. Phone/Fax

Practice location:
  • Phone: 773-698-6535
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146.016219
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: