Healthcare Provider Details

I. General information

NPI: 1104486604
Provider Name (Legal Business Name): JENNA LYNN BUMBER LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 12/15/2022
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 W PETERSON AVE STE 202
CHICAGO IL
60646
US

IV. Provider business mailing address

5010 W PENSACOLA AVE BSMT UNIT
CHICAGO IL
60641-1547
US

V. Phone/Fax

Practice location:
  • Phone: 773-774-4444
  • Fax:
Mailing address:
  • Phone: 773-774-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180014637
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: