Healthcare Provider Details

I. General information

NPI: 1770053738
Provider Name (Legal Business Name): JENNIFER ELISE O'HARE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2018
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24821 W 135TH ST
PLAINFIELD IL
60544-5413
US

IV. Provider business mailing address

13400 S ROUTE 59 UNIT 116
PLAINFIELD IL
60585-5830
US

V. Phone/Fax

Practice location:
  • Phone: 815-254-7400
  • Fax: 815-254-7408
Mailing address:
  • Phone: 815-254-7400
  • Fax: 815-254-7408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178010716
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180011869
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: