Healthcare Provider Details

I. General information

NPI: 1588528251
Provider Name (Legal Business Name): KIRSTEN NICOLE JEFFERSON CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N STATE ROUTE 31
CRYSTAL LAKE IL
60012-3714
US

IV. Provider business mailing address

1221 CARDINAL DR
ALGONQUIN IL
60102-2547
US

V. Phone/Fax

Practice location:
  • Phone: 815-261-3450
  • Fax: 815-261-3451
Mailing address:
  • Phone: 815-261-3450
  • Fax: 815-261-3451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCADC-45326
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: