Healthcare Provider Details

I. General information

NPI: 1093352080
Provider Name (Legal Business Name): JENNIFER JEDRZEJCZAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2019
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 MOON LAKE BLVD
HOFFMAN ESTATES IL
60169-1010
US

IV. Provider business mailing address

435 BELMONT LN
BARTLETT IL
60103-8958
US

V. Phone/Fax

Practice location:
  • Phone: 847-755-8579
  • Fax:
Mailing address:
  • Phone: 630-390-9008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number071010198
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071010198
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071010198
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: