MEDICARE: JACLYN ANN SULLIVAN

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	237700000X	Hearing Instrument Specialist	2676	IL
2	235Z00000X	Speech-Language Pathologist	146.011457	IL

General Provider Information

NPI Number	:	1700432424
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACLYN ANN SULLIVAN

Provider Business Mailing Address
First Line	:	12910 S LA GRANGE RD
Second Line	:
City	:	PALOS PARK
State	:	IL
Zip	:	60464-1717
Country	:	US
Telephone Number	:	708-448-1234
Fax Number	:

Provider Business Practice Location Address
First Line	:	12910 S LA GRANGE RD
Second Line	:
City	:	PALOS PARK
State	:	IL
Zip	:	60464-1717
Country	:	US
Telephone Number	:	708-448-1234
Fax Number	:

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

Provider Enumeration Date	:	08/18/2019
Last Update Date	:	04/24/2024

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