Provider Demographics
NPI:1417294927
Name:PRONGER, JENNA ANN
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:ANN
Last Name:PRONGER
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 1:10360 S 84TH AVE
Mailing Address - Street 2:
Mailing Address - City:PALOS HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60465-1702
Mailing Address - Country:US
Mailing Address - Phone:708-983-3101
Mailing Address - Fax:
Practice Address - Street 1:4201 W 93RD ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-1998
Practice Address - Country:US
Practice Address - Phone:708-423-0150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-04
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL178.008085OtherLICENSED PROFESSIONAL COUNSELOR
IL180.009347OtherLICENSED CLINICAL PROFESSIONAL COUNSELOR