Provider Demographics
NPI:1043475122
Name:KILLAM, JENNIE MARIE
Entity type:Individual
Prefix:MRS
First Name:JENNIE
Middle Name:MARIE
Last Name:KILLAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31281 KILLAM RD.
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:IL
Mailing Address - Zip Code:62640-8629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8801 WERNER RD
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:IL
Practice Address - Zip Code:62670-6805
Practice Address - Country:US
Practice Address - Phone:217-971-1882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-28
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist