1174969208 NPI number — MRS. JESSICA CAROLYN BRALEY KEENAN MA, CCC-SLP/L, IBCLC

Table of content: MRS. JESSICA CAROLYN BRALEY KEENAN MA, CCC-SLP/L, IBCLC (NPI 1174969208)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174969208 NPI number — MRS. JESSICA CAROLYN BRALEY KEENAN MA, CCC-SLP/L, IBCLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEENAN
Provider First Name:
JESSICA
Provider Middle Name:
CAROLYN BRALEY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA, CCC-SLP/L, IBCLC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRALEY
Provider Other First Name:
JESSICA
Provider Other Middle Name:
CAROLYN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA, CCC-SLP/L, IBCLC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174969208
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
910 KNOTTINGHAM DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OTTAWA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61350-4226
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-228-7184
Provider Business Mailing Address Fax Number:
480-697-5716

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 KNOTTINGHAM DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OTTAWA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61350-4226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-228-7184
Provider Business Practice Location Address Fax Number:
480-697-5716
Provider Enumeration Date:
05/15/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  146.012090 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com