Healthcare Provider Details

I. General information

NPI: 1184513475
Provider Name (Legal Business Name): MALLORY KAITLYN JUMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2025
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 N AIRLITE ST # 1G14
ELGIN IL
60123-4988
US

IV. Provider business mailing address

6620 CENTURY AVE APT 132
MIDDLETON WI
53562-2274
US

V. Phone/Fax

Practice location:
  • Phone: 847-695-5904
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7336-154
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: