Provider Demographics
NPI:1033565833
Name:FAST, JENNIFER LEE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LEE
Last Name:FAST
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:LEE
Other - Last Name:JEZIORSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:18 CAMPUS CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-2342
Mailing Address - Country:US
Mailing Address - Phone:708-334-7508
Mailing Address - Fax:
Practice Address - Street 1:211 E 7TH ST STE 620
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-3218
Practice Address - Country:US
Practice Address - Phone:800-370-3651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008255103TC0700X
TX38062103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical