MEDICARE: MS. JEANNE MIMI GOURGUECHON DTH

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	JG39350902P	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	JG39350902P	OTHER	IL	EARLY INTERVENTION

General Provider Information

NPI Number	:	1871622274
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JEANNE MIMI GOURGUECHON DTH

Provider Business Mailing Address
First Line	:	2042 W MORSE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60645-4955
Country	:	US
Telephone Number	:	773-495-6627
Fax Number	:	773-274-4276

Provider Business Practice Location Address
First Line	:	2042 W MORSE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60645-4955
Country	:	US
Telephone Number	:	773-495-6627
Fax Number	:	773-274-4276

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

Provider Enumeration Date	:	03/04/2007
Last Update Date	:	07/08/2007

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Directions to “ MS. JEANNE MIMI GOURGUECHON DTH” Practice Location

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