Provider Demographics
NPI:1245048834
Name:GIDMAN-DUTTA, JENNA
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:GIDMAN-DUTTA
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 1:4315 CHELSEA MANOR CIR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-3275
Mailing Address - Country:US
Mailing Address - Phone:574-286-8375
Mailing Address - Fax:
Practice Address - Street 1:1315 BUTTERFIELD RD STE 208
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-5602
Practice Address - Country:US
Practice Address - Phone:630-441-4415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-27
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071011335103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical