Provider Demographics
NPI:1225426570
Name:PELLICANO, JENNIFER LYNN (PSYD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:PELLICANO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 E MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2287
Mailing Address - Country:US
Mailing Address - Phone:630-377-6613
Mailing Address - Fax:630-377-6225
Practice Address - Street 1:207 E CHURCH ST
Practice Address - Street 2:SUITE A
Practice Address - City:SANDWICH
Practice Address - State:IL
Practice Address - Zip Code:60548-9803
Practice Address - Country:US
Practice Address - Phone:815-786-8606
Practice Address - Fax:815-786-1541
Is Sole Proprietor?:No
Enumeration Date:2015-01-08
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008942103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400201117Medicare PIN