Provider Demographics
NPI:1144236118
Name:SUNDBERG, JEFFREY BYRON (LCSW)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:BYRON
Last Name:SUNDBERG
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 A EAST STATE STREET
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61110-7044
Mailing Address - Country:US
Mailing Address - Phone:815-332-8342
Mailing Address - Fax:815-332-8342
Practice Address - Street 1:610 E STATE ST
Practice Address - Street 2:A
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-1038
Practice Address - Country:US
Practice Address - Phone:815-332-8342
Practice Address - Fax:815-332-8342
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical