Provider Demographics
NPI:1902168081
Name:JACKIW, TEAGAN MARIE (MS SLP-CF)
Entity Type:Individual
Prefix:MISS
First Name:TEAGAN
Middle Name:MARIE
Last Name:JACKIW
Suffix:
Gender:F
Credentials:MS SLP-CF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10624 S KILBOURN AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-5342
Mailing Address - Country:US
Mailing Address - Phone:708-828-4317
Mailing Address - Fax:
Practice Address - Street 1:10624 S KILBOURN AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-5342
Practice Address - Country:US
Practice Address - Phone:708-828-4317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242002231235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist