Provider Demographics
NPI:1720293392
Name:CONVISER, JENNY H (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNY
Middle Name:H
Last Name:CONVISER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 1625
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2615
Mailing Address - Country:US
Mailing Address - Phone:312-409-6800
Mailing Address - Fax:
Practice Address - Street 1:737 N MICHIGAN AVE
Practice Address - Street 2:SUITE 1625
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2615
Practice Address - Country:US
Practice Address - Phone:312-409-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.004492103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1607378OtherBCBS PROVIDER NUMBER
IL071.004492OtherSTATE LICENSE NO
IL071.004492OtherSTATE LICENSE NO