Provider Demographics
NPI:1083912034
Name:STINE, JEFFRY WAYNE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JEFFRY
Middle Name:WAYNE
Last Name:STINE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:JEFFRY
Other - Middle Name:
Other - Last Name:STINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2450 W ADDISON ST APT 2A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-5960
Mailing Address - Country:US
Mailing Address - Phone:224-388-3633
Mailing Address - Fax:847-929-4513
Practice Address - Street 1:900 SKOKIE BLVD STE 115
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062
Practice Address - Country:US
Practice Address - Phone:224-388-3633
Practice Address - Fax:847-929-4513
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-28
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008039103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent