Provider Demographics
NPI:1235431974
Name:HANSEN, JEANNE M (LCSW)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:M
Last Name:HANSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JEANNE
Other - Middle Name:M
Other - Last Name:DOUGHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 19642
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9642
Mailing Address - Country:US
Mailing Address - Phone:217-545-8229
Mailing Address - Fax:217-545-2275
Practice Address - Street 1:901 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4833
Practice Address - Country:US
Practice Address - Phone:217-545-8229
Practice Address - Fax:217-545-2275
Is Sole Proprietor?:No
Enumeration Date:2010-12-01
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0092791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL256514007Medicare PIN