Healthcare Provider Details

I. General information

NPI: 1467992388
Provider Name (Legal Business Name): JENNIFER DAVIS M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2017
Last Update Date: 02/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2265 N CLYBOURN AVE
CHICAGO IL
60614-3052
US

IV. Provider business mailing address

2265 N CLYBOURN AVE
CHICAGO IL
60614-3052
US

V. Phone/Fax

Practice location:
  • Phone: 773-296-6700
  • Fax: 773-296-1131
Mailing address:
  • Phone: 773-296-6700
  • Fax: 773-296-1131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178012731
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: