Provider Demographics
NPI:1568181337
Name:WHITE, JENNIFER ANN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:KIESER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5119 N ASHLAND AVE BSMT UNIT
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1770
Mailing Address - Country:US
Mailing Address - Phone:269-365-8092
Mailing Address - Fax:
Practice Address - Street 1:6325 N SHERIDAN RD APT 1602
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-5718
Practice Address - Country:US
Practice Address - Phone:773-359-3505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.106668104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty