Provider Demographics
NPI:1710358270
Name:HENTRICH, JESSICA M
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:HENTRICH
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 1:500 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT ZION
Mailing Address - State:IL
Mailing Address - Zip Code:62549-1664
Mailing Address - Country:US
Mailing Address - Phone:217-433-3691
Mailing Address - Fax:
Practice Address - Street 1:500 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:MOUNT ZION
Practice Address - State:IL
Practice Address - Zip Code:62549-1664
Practice Address - Country:US
Practice Address - Phone:217-433-3691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0177331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical