MEDICARE: DR. RICHARA JENNINGS PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	071-007563	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	IL1583002	OTHER	IL	CMS MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	071-007563	OTHER	IL	IDFPR

General Provider Information

NPI Number	:	1669545208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARA JENNINGS PSYD

Provider Business Mailing Address
First Line	:	9449 S KEDZIE AVE
Second Line	:	STE 306
City	:	EVERGREEN PARK
State	:	IL
Zip	:	60805-2325
Country	:	US
Telephone Number	:	773-510-0104
Fax Number	:	708-620-8631

Provider Business Practice Location Address
First Line	:	10343 S WESTERN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-2410
Country	:	US
Telephone Number	:	773-238-2828
Fax Number	:	708-974-3845

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	06/04/2014

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