Provider Demographics
NPI:1609230366
Name:DAVIS, JENNIFER NICOLE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:NICOLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 W. PETERSON AVE
Mailing Address - Street 2:SUITE 401
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-5730
Mailing Address - Country:US
Mailing Address - Phone:773-282-2322
Mailing Address - Fax:773-282-2853
Practice Address - Street 1:4801 W. PETERSON AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-5730
Practice Address - Country:US
Practice Address - Phone:773-282-2322
Practice Address - Fax:773-282-2853
Is Sole Proprietor?:No
Enumeration Date:2016-04-08
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009192103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical