Basic Information
Provider Information | |||||||||
NPI: | 1235309444 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JACK JONES HEARING CENTERS, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HEARING TECH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 750 N COMMONS DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | AURORA | ||||||||
State: | IL | ||||||||
PostalCode: | 605047940 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6303035380 | ||||||||
FaxNumber: | 6303305385 | ||||||||
Practice Location | |||||||||
Address1: | 407 CANYON CREEK DR STE 108 | ||||||||
Address2: |   | ||||||||
City: | TEMPLE | ||||||||
State: | TX | ||||||||
PostalCode: | 765023292 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2547783736 | ||||||||
FaxNumber: | 2547712629 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/04/2008 | ||||||||
LastUpdateDate: | 08/24/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KENNEDY | ||||||||
AuthorizedOfficialFirstName: | DAWN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 6303035380 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/24/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |   | 237600000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |   | 237700000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |   | 332S00000X |   |   | Y |   | Suppliers | Hearing Aid Equipment |   |
ID Information
ID | Type | State | Issuer | Description | 112774802 | 05 | TX |   | MEDICAID | 0615164 | 01 | TX | AETNA | OTHER | 530294 | 01 | TX | BCBS | OTHER |