MEDICARE: SPROUT THERAPY SERVICES

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	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1689568057
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPROUT THERAPY SERVICES

Provider Business Mailing Address
First Line	:	2001 JEFFERSON ST STE 127
Second Line	:
City	:	QUINCY
State	:	IL
Zip	:	62301-5654
Country	:	US
Telephone Number	:	309-431-1817
Fax Number	:	309-406-6568

Provider Business Practice Location Address
First Line	:	2001 JEFFERSON ST STE 127
Second Line	:
City	:	QUINCY
State	:	IL
Zip	:	62301-5654
Country	:	US
Telephone Number	:	309-431-1817
Fax Number	:

Authorized Official
Title or Position	:	CO-OWNER, SPEECH-LANGUAGE PATHOLOGI
Name	:	JENNA DIETRICH
Credential	:
Telephone Number	:	217-440-0898

Provider Enumeration Date	:	06/09/2025
Last Update Date	:	06/16/2026

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Directions to “SPROUT THERAPY SERVICES ” Practice Location

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