Healthcare Provider Details

I. General information

NPI: 1902049653
Provider Name (Legal Business Name): JENNIFER RENEE SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2009
Last Update Date: 04/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2416 E WASHINGTON ST SUITE G
BLOOMINGTON IL
61704-4472
US

IV. Provider business mailing address

4634 CIRCLE DR
HEYWORTH IL
61745-9462
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-5050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0-07-2352
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: