Healthcare Provider Details

I. General information

NPI: 1902544463
Provider Name (Legal Business Name): JENAYA ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2022
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1136 S DELANO CT W STE B201
CHICAGO IL
60605-3734
US

IV. Provider business mailing address

15127 S 73RD AVE STE G
ORLAND PARK IL
60462-3425
US

V. Phone/Fax

Practice location:
  • Phone: 708-845-5500
  • Fax: 708-845-5505
Mailing address:
  • Phone: 708-845-5500
  • Fax: 708-845-5505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149021625
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: