Provider Demographics
NPI:1013412931
Name:YATES, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:YATES
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 1:3233 MATHERS RD STE A
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-7900
Mailing Address - Country:US
Mailing Address - Phone:217-414-2064
Mailing Address - Fax:
Practice Address - Street 1:3233 MATHERS RD STE A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-7900
Practice Address - Country:US
Practice Address - Phone:217-899-5412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-25
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.011471101YP2500X
IL071.009981103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty