Provider Demographics
NPI:1235423146
Name:STANLEY, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:STANLEY
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 1:210 S 5TH ST STE 202
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2700
Mailing Address - Country:US
Mailing Address - Phone:630-945-3867
Mailing Address - Fax:
Practice Address - Street 1:210 S 5TH ST STE 202
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2700
Practice Address - Country:US
Practice Address - Phone:630-945-3867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.012757225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist