MEDICARE: MS. JENNIFER L GROSSHEIDER

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1740595164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER L GROSSHEIDER

Provider Business Mailing Address
First Line	:	1530 S STATE ST
Second Line	:	SUITE 15 N
City	:	CHICAGO
State	:	IL
Zip	:	60605-2973
Country	:	US
Telephone Number	:	630-673-1211
Fax Number	:	773-326-0725

Provider Business Practice Location Address
First Line	:	1530 S STATE ST
Second Line	:	SUITE 15 N
City	:	CHICAGO
State	:	IL
Zip	:	60605-2973
Country	:	US
Telephone Number	:	630-673-1211
Fax Number	:	773-326-0725

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

Provider Enumeration Date	:	08/10/2010
Last Update Date	:	08/10/2010

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