Provider Demographics
NPI:1679820575
Name:DICKENS, JENNIFER LYNN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:DICKENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:MAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:570 LOGUE CIR
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:IL
Mailing Address - Zip Code:61360-9671
Mailing Address - Country:US
Mailing Address - Phone:815-954-3818
Mailing Address - Fax:
Practice Address - Street 1:260 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:IL
Practice Address - Zip Code:61360-9414
Practice Address - Country:US
Practice Address - Phone:815-357-6858
Practice Address - Fax:815-357-6857
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.009909225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist