Healthcare Provider Details

I. General information

NPI: 1356732085
Provider Name (Legal Business Name): JAMIE DEYOUNG M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2015
Last Update Date: 02/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

759 KANE ST
SOUTH ELGIN IL
60177-1418
US

IV. Provider business mailing address

PO BOX 504469
SAINT LOUIS MO
63150-4469
US

V. Phone/Fax

Practice location:
  • Phone: 847-697-3310
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146011079
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: