Healthcare Provider Details

I. General information

NPI: 1588574818
Provider Name (Legal Business Name): CIERRA JINKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11325 S CHAMPLAIN AVE
CHICAGO IL
60628-5121
US

IV. Provider business mailing address

11325 S CHAMPLAIN AVE
CHICAGO IL
60628-5121
US

V. Phone/Fax

Practice location:
  • Phone: 773-954-1205
  • Fax:
Mailing address:
  • Phone: 773-954-1205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: