Provider Demographics
NPI:1639623648
Name:FAHEY, JENNA
Entity Type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:
Last Name:FAHEY
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 1:70 E LAKE ST
Mailing Address - Street 2:SUITE 222
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-5959
Mailing Address - Country:US
Mailing Address - Phone:312-350-2462
Mailing Address - Fax:
Practice Address - Street 1:70 E LAKE ST
Practice Address - Street 2:SUITE 222
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-5959
Practice Address - Country:US
Practice Address - Phone:312-350-2462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208.000224106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist