MEDICARE: JENNIFER NICOLE WALLEN HIS

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AS5065	OTHER	FL	HIS LICENSE

General Provider Information

NPI Number	:	1760872139
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER NICOLE WALLEN HIS

Provider Business Mailing Address
First Line	:	215 SHUMAN BLVD
Second Line	:	STE. 401
City	:	NAPERVILLE
State	:	IL
Zip	:	60563-8458
Country	:	US
Telephone Number	:	630-303-5380
Fax Number	:	978-313-6824

Provider Business Practice Location Address
First Line	:	1722 DEL PRADO BLVD S
Second Line	:	STE 2
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-5525
Country	:	US
Telephone Number	:	239-458-7900
Fax Number	:	239-458-9977

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

Provider Enumeration Date	:	01/23/2015
Last Update Date	:	01/23/2015

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