Provider Demographics
NPI:1326581117
Name:BEVERLY, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BEVERLY
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 1:333 W PIERCE RD
Mailing Address - Street 2:120
Mailing Address - City:ITASCA
Mailing Address - State:IL
Mailing Address - Zip Code:60143-3116
Mailing Address - Country:US
Mailing Address - Phone:630-773-1985
Mailing Address - Fax:630-773-1988
Practice Address - Street 1:333 W PIERCE RD
Practice Address - Street 2:120
Practice Address - City:ITASCA
Practice Address - State:IL
Practice Address - Zip Code:60143-3116
Practice Address - Country:US
Practice Address - Phone:630-773-1985
Practice Address - Fax:630-773-1988
Is Sole Proprietor?:No
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health