Provider Demographics
NPI:1215086814
Name:SHACKELFORD, JILL K (CCC-SLP)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:K
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:638 S CROSS ST
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-2111
Mailing Address - Country:US
Mailing Address - Phone:630-444-0077
Mailing Address - Fax:630-444-0078
Practice Address - Street 1:40W310 LAFOX RD
Practice Address - Street 2:SUITE 1A
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-6588
Practice Address - Country:US
Practice Address - Phone:630-444-0077
Practice Address - Fax:630-444-0078
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146006263235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400099172Medicare PIN