MEDICARE: MRS. JENNIFER DARLENE SLATER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst
2	104100000X	Social Worker

General Provider Information

NPI Number	:	1619269040
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER DARLENE SLATER

Provider Business Mailing Address
First Line	:	18 KARA CT
Second Line	:
City	:	DANVERS
State	:	IL
Zip	:	61732-9078
Country	:	US
Telephone Number	:	309-242-7051
Fax Number	:

Provider Business Practice Location Address
First Line	:	18 KARA CT
Second Line	:
City	:	DANVERS
State	:	IL
Zip	:	61732-9078
Country	:	US
Telephone Number	:	309-242-7051
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2011
Last Update Date	:	05/04/2011

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