Provider Demographics
NPI:1972628790
Name:AMOS, JACLYN (MS, CCC-SLP/L)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:AMOS
Suffix:
Gender:F
Credentials:MS, CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1258 DUNAMON DR
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-1949
Mailing Address - Country:US
Mailing Address - Phone:847-533-4723
Mailing Address - Fax:
Practice Address - Street 1:1019 E CHICAGO ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-6822
Practice Address - Country:US
Practice Address - Phone:847-429-6131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146008593235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL235Z00000XOtherSPEECH PATHOLOGIST