Provider Demographics
NPI:1063034346
Name:STEC, JENNIFER AMELIA
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:AMELIA
Last Name:STEC
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 1:2018 W 101ST PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-2071
Mailing Address - Country:US
Mailing Address - Phone:773-799-4357
Mailing Address - Fax:
Practice Address - Street 1:10801 S WESTERN AVE STE 2B
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-3225
Practice Address - Country:US
Practice Address - Phone:708-586-7357
Practice Address - Fax:773-253-8410
Is Sole Proprietor?:No
Enumeration Date:2020-05-10
Last Update Date:2020-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.015929101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL47-1904908Medicaid