Provider Demographics
NPI:1063743144
Name:JENNINGS, MOIRA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MOIRA
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 S DEARBORN ST
Mailing Address - Street 2:#34
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-1648
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1812 S DEARBORN ST
Practice Address - Street 2:#34
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-1648
Practice Address - Country:US
Practice Address - Phone:312-328-1245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-28
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.008791235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist