Provider Demographics
NPI:1821631888
Name:SALT, JEFF (DCLINPSY BSC)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:SALT
Suffix:
Gender:M
Credentials:DCLINPSY BSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 S MONTCLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-6357
Mailing Address - Country:US
Mailing Address - Phone:224-227-0497
Mailing Address - Fax:
Practice Address - Street 1:3S140 BARKLEY AVE
Practice Address - Street 2:
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-1505
Practice Address - Country:US
Practice Address - Phone:331-431-4006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007484103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent