=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447604947
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER LOUISE DECANT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2016
-----------------------------------------------------
Last Update Date | 01/23/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 811 W EVERGREEN AVE STE 404
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60642-7113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-242-1665
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 225 S RAMMER AVE
-----------------------------------------------------
City | ARLINGTON HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60004-6868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-558-9360
-----------------------------------------------------
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 | 242.003657
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------