Provider Demographics
NPI:1073039350
Name:MAMAK, JENNIFER ANN (EDS)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANN
Last Name:MAMAK
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:MCDONOUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EDS
Mailing Address - Street 1:1470 RAVEN DR
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-4510
Mailing Address - Country:US
Mailing Address - Phone:630-771-2420
Mailing Address - Fax:
Practice Address - Street 1:1470 RAVEN DR
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-4510
Practice Address - Country:US
Practice Address - Phone:630-771-2420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1848773103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool