Active NPI
Jacqueline Wagner, M.S., CCC-SLP/L
- Speech-Language Pathologist
- Chicago, IL
National Provider Identifier
1104131648
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Speech-Language Pathologist
- License
- 146009849
- Practice address
- 1640 N Wells St
Suite 103
Chicago, IL 60614-6087 - Phone
- (312) 642-4300
- NPI assigned
- Aug 9, 2010
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Speech-Language Pathologist | 235Z00000X | 146009849 | IL | Primary |
Addresses
Primary practice location
1640 N Wells St
Suite 103
Chicago, IL 60614-6087
Mailing address
1640 N Wells St
Suite 103
Chicago, IL 60614-6087
Phone (312) 642-4300
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Master of Science
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 146009849 | IL | MD | Speech-Language Pathologist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Oak Tree Developmental Center | Speech-Language Pathologist | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1281312000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1281312000000",
"number": "1104131648",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1640 N WELLS ST",
"address_2": "SUITE 103",
"city": "CHICAGO",
"state": "IL",
"postal_code": "606146087",
"telephone_number": "312-642-4300"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1640 N WELLS ST",
"address_2": "SUITE 103",
"city": "CHICAGO",
"state": "IL",
"postal_code": "606146087",
"telephone_number": "312-642-4300"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGNER",
"first_name": "JACQUELINE",
"credential": "M.S., CCC-SLP/L",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2010-08-09",
"last_updated": "2010-08-09",
"status": "A"
},
"taxonomies": [
{
"code": "235Z00000X",
"taxonomy_group": "",
"desc": "Speech-Language Pathologist",
"state": "IL",
"license": "146009849",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Chicago, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 9, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.