Healthcare Provider Details

I. General information

NPI: 1255470175
Provider Name (Legal Business Name): JENNIFER ANN SCANLON M.ED., LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 W DIVERSEY PKWY SUITE 2
CHICAGO IL
60614-6163
US

IV. Provider business mailing address

435 W DIVERSEY PKWY SUITE 2
CHICAGO IL
60614-6163
US

V. Phone/Fax

Practice location:
  • Phone: 773-525-5539
  • Fax: 773-935-0928
Mailing address:
  • Phone: 773-525-5539
  • Fax: 773-935-0928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: