Healthcare Provider Details

I. General information

NPI: 1740492891
Provider Name (Legal Business Name): JENNIFER LYNN FORD LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5547 N RAVENSWOOD AVE
CHICAGO IL
60640-1125
US

IV. Provider business mailing address

1933 W IRVING PARK RD UNIT 301
CHICAGO IL
60613-5180
US

V. Phone/Fax

Practice location:
  • Phone: 773-506-3044
  • Fax: 773-769-9103
Mailing address:
  • Phone: 773-412-7711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: