Healthcare Provider Details

I. General information

NPI: 1376252007
Provider Name (Legal Business Name): JEREMY PHELPS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2022
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 S MCHENRY AVE
CRYSTAL LAKE IL
60014-7449
US

IV. Provider business mailing address

970 S MCHENRY AVE
CRYSTAL LAKE IL
60014-7449
US

V. Phone/Fax

Practice location:
  • Phone: 815-322-9823
  • Fax: 815-455-7510
Mailing address:
  • Phone: 815-322-9823
  • Fax: 815-455-7510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number180017263
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: