Provider Demographics
NPI:1780807222
Name:HORTENSTINE-GROHLER, JENNIFER ANNETTE (L C P C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNETTE
Last Name:HORTENSTINE-GROHLER
Suffix:
Gender:F
Credentials:L C P C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 18C
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IL
Mailing Address - Zip Code:61951-8712
Mailing Address - Country:US
Mailing Address - Phone:217-728-8848
Mailing Address - Fax:
Practice Address - Street 1:1770 E LAKE SHORE DR
Practice Address - Street 2:SUITE #208
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3832
Practice Address - Country:US
Practice Address - Phone:217-428-1900
Practice Address - Fax:217-428-0358
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.001685101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional