Provider Demographics
NPI:1538428941
Name:HAVENS, JODIE M (MS CCC-SLP/L)
Entity type:Individual
Prefix:MRS
First Name:JODIE
Middle Name:M
Last Name:HAVENS
Suffix:
Gender:F
Credentials:MS CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SHELDON
Mailing Address - State:IL
Mailing Address - Zip Code:60966-8309
Mailing Address - Country:US
Mailing Address - Phone:815-644-2425
Mailing Address - Fax:
Practice Address - Street 1:245 S 6TH ST
Practice Address - Street 2:
Practice Address - City:SHELDON
Practice Address - State:IL
Practice Address - Zip Code:60966-8309
Practice Address - Country:US
Practice Address - Phone:815-644-2425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1460107442355S0801X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant