Provider Demographics
NPI:1205452596
Name:GORMAN, JENNIFER M (MS, SSP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:GORMAN
Suffix:
Gender:F
Credentials:MS, SSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9162 GREENCASTLE LN
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-3235
Mailing Address - Country:US
Mailing Address - Phone:217-778-0136
Mailing Address - Fax:
Practice Address - Street 1:6509 POWELL ST
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60516-2721
Practice Address - Country:US
Practice Address - Phone:630-719-5850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2009737103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool