Provider Demographics
NPI:1184605834
Name:SCHENCK, JENNIFER MICHELLE (PMHNP, RN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:SCHENCK
Suffix:
Gender:F
Credentials:PMHNP, RN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MICHELLE
Other - Last Name:CYR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, NP
Mailing Address - Street 1:520 FULLERTON RD STE B
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2901
Mailing Address - Country:US
Mailing Address - Phone:618-688-2459
Mailing Address - Fax:618-257-0641
Practice Address - Street 1:520 FULLERTON RD STE B
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2901
Practice Address - Country:US
Practice Address - Phone:618-688-2459
Practice Address - Fax:618-257-0641
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL377-001592363LP0808X, 363LP0808X
WARN00161455163W00000X
WA60050265363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL87-2530297OtherINDIVIDUAL