Basic Information
| Provider Information | |||||||||
| NPI: | 1902107782 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KICIELINSKI | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 234 S LIBERTY RD | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622942830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184209222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3354 JEROME LN | ||||||||
| Address2: | |||||||||
| City: | CAHOKIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622062604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183379400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2010 | ||||||||
| LastUpdateDate: | 11/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 146.010646 | IL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.