Healthcare Provider Details

I. General information

NPI: 1902667694
Provider Name (Legal Business Name): JENNIFER GAIL KOWALKOWSKI MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2024
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3613 APPALOOSA DR
JOLIET IL
60435-1594
US

IV. Provider business mailing address

3613 APPALOOSA DR
JOLIET IL
60435-1594
US

V. Phone/Fax

Practice location:
  • Phone: 815-953-0422
  • Fax:
Mailing address:
  • Phone: 815-953-0422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1780061
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: