=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437677416
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. JAMIE RENEE GARRETT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2017
-----------------------------------------------------
Last Update Date | 08/30/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 805 N CHEROKEE ST
-----------------------------------------------------
City | TAYLORVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62568-1450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-824-3315
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 759 N 1350 EAST RD
-----------------------------------------------------
City | OWANECO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62555-5517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-972-8534
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 146.007898
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------