Provider Demographics
NPI:1417134537
Name:CALDWELL, JENNIFER (MA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CALDWELL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 REVERE DR STE 120
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-8005
Mailing Address - Country:US
Mailing Address - Phone:941-485-0121
Mailing Address - Fax:941-485-0591
Practice Address - Street 1:417 COMMERCIAL CT STE C
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-1655
Practice Address - Country:US
Practice Address - Phone:941-485-0121
Practice Address - Fax:941-485-0591
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-31
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH11890101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health