Provider Demographics
NPI:1417592775
Name:HERNANDEZ, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HERNANDEZ
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 1:9830 BRANDT AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-3029
Mailing Address - Country:US
Mailing Address - Phone:708-952-4392
Mailing Address - Fax:
Practice Address - Street 1:9830 BRANDT AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-3029
Practice Address - Country:US
Practice Address - Phone:708-952-4392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-11
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL00Medicaid