Provider Demographics
NPI:1982225322
Name:JERRY, KRISTINA LYNN
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:LYNN
Last Name:JERRY
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 1:7880 GENEVA DR
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-5152
Mailing Address - Country:US
Mailing Address - Phone:949-677-3790
Mailing Address - Fax:
Practice Address - Street 1:4109 67TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-3836
Practice Address - Country:US
Practice Address - Phone:262-652-9830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-27
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4617-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional