Provider Demographics
NPI:1891037073
Name:THOMPSON, JACKIE L (MA-CCC-A)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:L
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MA-CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 E NORRIS DR
Mailing Address - Street 2:ATTN: AUDIOLOGY
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-1604
Mailing Address - Country:US
Mailing Address - Phone:815-431-5327
Mailing Address - Fax:815-431-5691
Practice Address - Street 1:1050 E NORRIS DR
Practice Address - Street 2:SUITE 2A
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-1605
Practice Address - Country:US
Practice Address - Phone:815-431-5327
Practice Address - Fax:815-431-5691
Is Sole Proprietor?:No
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147000801231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist