Healthcare Provider Details

I. General information

NPI: 1457568982
Provider Name (Legal Business Name): JACY MARIE SHOENER M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2511 IMGRUND RD
NORTH AURORA IL
60542-2120
US

IV. Provider business mailing address

2511 IMGRUND RD
NORTH AURORA IL
60542-2120
US

V. Phone/Fax

Practice location:
  • Phone: 630-907-6171
  • Fax: 630-907-6171
Mailing address:
  • Phone: 630-907-6171
  • Fax: 630-907-6171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: