Healthcare Provider Details

I. General information

NPI: 1346550795
Provider Name (Legal Business Name): JOAN ELLEN GJESFJELD LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2010
Last Update Date: 02/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 BEECH ST BLDG. 13 B
NORMAL IL
61761-1493
US

IV. Provider business mailing address

704 COUNTRY LN
BLOOMINGTON IL
61704-6261
US

V. Phone/Fax

Practice location:
  • Phone: 309-336-3284
  • Fax:
Mailing address:
  • Phone: 309-336-3284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149016133
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: