Provider Demographics
NPI:1114503570
Name:NALLS, JENNIFER D
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:D
Last Name:NALLS
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 1:4644 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-1808
Mailing Address - Country:US
Mailing Address - Phone:708-747-5967
Mailing Address - Fax:
Practice Address - Street 1:9641 W 153RD ST STE 48
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3777
Practice Address - Country:US
Practice Address - Phone:708-963-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178014138101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional