Provider Demographics
NPI:1609108703
Name:BIDWELL, JEREMY TODD (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:TODD
Last Name:BIDWELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 DEAN ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-3220
Mailing Address - Country:US
Mailing Address - Phone:815-344-5061
Mailing Address - Fax:815-344-5072
Practice Address - Street 1:111 DEAN ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-3220
Practice Address - Country:US
Practice Address - Phone:815-344-5061
Practice Address - Fax:815-344-5072
Is Sole Proprietor?:No
Enumeration Date:2010-02-01
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007831103TC0700X
IL074.000011103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical