Basic Information
| Provider Information | |||||||||
| NPI: | 1942468095 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLGREN | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | M.S. CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1860 W WINCHESTER RD STE 108 | ||||||||
| Address2: | |||||||||
| City: | LIBERTYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600485312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475739486 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1860 W WINCHESTER RD STE 108 | ||||||||
| Address2: | |||||||||
| City: | LIBERTYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600485312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475739486 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2008 | ||||||||
| LastUpdateDate: | 12/11/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 001846 | IA | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 146.009599 | IL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.