Healthcare Provider Details

I. General information

NPI: 1003592577
Provider Name (Legal Business Name): JENNIFER MENA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2023
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2835 N SHEFFIELD AVE STE 304308
CHICAGO IL
60657-5081
US

IV. Provider business mailing address

1110 N HAMLIN AVE
CHICAGO IL
60651-3841
US

V. Phone/Fax

Practice location:
  • Phone: 630-866-5666
  • Fax: 630-358-6907
Mailing address:
  • Phone: 219-218-3717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number150.106058
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: