Healthcare Provider Details

I. General information

NPI: 1902525108
Provider Name (Legal Business Name): MRS. JENNIFER SARA MILDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2022
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 SYCAMORE RD
DEKALB IL
60115-2483
US

IV. Provider business mailing address

570 S PEACE RD
SYCAMORE IL
60178-1656
US

V. Phone/Fax

Practice location:
  • Phone: 815-758-8616
  • Fax:
Mailing address:
  • Phone: 773-220-7698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: