Provider Demographics
NPI:1427401504
Name:JEANINE STANDARD METAMORPHOSIS INC
Entity Type:Organization
Organization Name:JEANINE STANDARD METAMORPHOSIS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEANINE
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:STANDARD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:309-740-2171
Mailing Address - Street 1:8 S MAIN ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-2677
Mailing Address - Country:US
Mailing Address - Phone:309-740-2171
Mailing Address - Fax:309-740-2171
Practice Address - Street 1:8 S MAIN ST
Practice Address - Street 2:SUITE 205
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2677
Practice Address - Country:US
Practice Address - Phone:309-740-2171
Practice Address - Fax:309-740-2171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-13
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007101103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK30552Medicare UPIN