Provider Demographics
NPI:1841618659
Name:GRANSTROM, JENNY ELISABETH
Entity Type:Individual
Prefix:MS
First Name:JENNY
Middle Name:ELISABETH
Last Name:GRANSTROM
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 1:1005 BUCCANEER DR APT 5
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-5214
Mailing Address - Country:US
Mailing Address - Phone:847-293-3331
Mailing Address - Fax:
Practice Address - Street 1:1005 BUCCANEER DR APT 5
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-5214
Practice Address - Country:US
Practice Address - Phone:847-293-3331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2479988222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist