Provider Demographics
NPI:1982241212
Name:WAINER, JESSICA DAWN (SSP)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:DAWN
Last Name:WAINER
Suffix:
Gender:F
Credentials:SSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 N SCHMIDT RD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-2689
Mailing Address - Country:US
Mailing Address - Phone:630-759-9300
Mailing Address - Fax:
Practice Address - Street 1:150 N SCHMIDT RD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2689
Practice Address - Country:US
Practice Address - Phone:630-759-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-05
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2453657103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty