Provider Demographics
NPI:1831820547
Name:JENNA REID YATES, PH.D., LICENSED CLINICAL PSYCHOLOGIST, LLC
Entity type:Organization
Organization Name:JENNA REID YATES, PH.D., LICENSED CLINICAL PSYCHOLOGIST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:YATES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:217-899-5412
Mailing Address - Street 1:3233 MATHERS RD STE A
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-7900
Mailing Address - Country:US
Mailing Address - Phone:121-741-4206
Mailing Address - Fax:
Practice Address - Street 1:3233 MATHERS RD STE A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-7900
Practice Address - Country:US
Practice Address - Phone:217-414-2064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty