Healthcare Provider Details

I. General information

NPI: 1902906324
Provider Name (Legal Business Name): THE JUNIPER CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 05/17/2024
Certification Date: 05/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 RENAISSANCE DRIVE SUITE 320
PARK RIDGE IL
60068-1471
US

IV. Provider business mailing address

1440 RENAISSANCE DRIVE SUITE 320
PARK RIDGE IL
60068-1471
US

V. Phone/Fax

Practice location:
  • Phone: 847-759-9110
  • Fax: 847-759-9440
Mailing address:
  • Phone: 847-759-9110
  • Fax: 224-985-2119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. MARGO M. JACQUOT
Title or Position: PRESIDENT
Credential: PSY D
Phone: 847-759-9110