Provider Demographics
NPI:1790181253
Name:EDIDIN, JENNIFER PALEY (PHD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:PALEY
Last Name:EDIDIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 W FRONTAGE RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-1204
Mailing Address - Country:US
Mailing Address - Phone:847-441-4433
Mailing Address - Fax:847-441-4430
Practice Address - Street 1:790 W FRONTAGE RD
Practice Address - Street 2:SUITE 209
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-1204
Practice Address - Country:US
Practice Address - Phone:847-441-4433
Practice Address - Fax:847-441-4430
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-11
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-008227103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent