Provider Demographics
NPI:1093352080
Name:JEDRZEJCZAK, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:JEDRZEJCZAK
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 1:435 BELMONT LN
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-8958
Mailing Address - Country:US
Mailing Address - Phone:630-390-9008
Mailing Address - Fax:
Practice Address - Street 1:1650 MOON LAKE BLVD
Practice Address - Street 2:
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169-1010
Practice Address - Country:US
Practice Address - Phone:847-755-8579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071010198103TH0004X, 103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical