Provider Demographics
NPI:1306380100
Name:NESNIDAL, JAMIE LYNN
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:NESNIDAL
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 1:2392 PUTNAM DR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60565-3044
Mailing Address - Country:US
Mailing Address - Phone:630-853-9280
Mailing Address - Fax:
Practice Address - Street 1:452 N EOLA RD
Practice Address - Street 2:SUITE A
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60502-9612
Practice Address - Country:US
Practice Address - Phone:630-999-0401
Practice Address - Fax:630-423-9669
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-16-26554106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILBACB358711OtherBACB