Provider Demographics
NPI:1467160853
Name:LISS, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LISS
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 1:1211 FARMINGTON LAKES DR
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-5109
Mailing Address - Country:US
Mailing Address - Phone:630-509-4166
Mailing Address - Fax:
Practice Address - Street 1:1211 FARMINGTON LAKES DR
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-5109
Practice Address - Country:US
Practice Address - Phone:630-509-4166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician