Basic Information
| Provider Information | |||||||||
| NPI: | 1134115256 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACK JONES HEARING CENTERS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 750 N COMMONS DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605047940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303035380 | ||||||||
| FaxNumber: | 6303035385 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 S HENDERSON ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761041017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173352583 | ||||||||
| FaxNumber: | 8173352597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 08/24/2021 | ||||||||
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| AuthorizedOfficialLastName: | KENNEDY | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP, FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6303035380 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 237700000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 231H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 332S00000X | Y | Suppliers | Hearing Aid Equipment |
ID Information
| ID | Type | State | Issuer | Description | 530294 | 01 | TX | BCBS | OTHER | 022467701 | 05 | TX | MEDICAID | 112774801 | 05 | TX | MEDICAID | 022068301 | 05 | TX | MEDICAID | 022466901 | 05 | TX | MEDICAID | 0615164 | 01 | TX | AETNA | OTHER | 112774803 | 05 | TX | MEDICAID |