Healthcare Provider Details

I. General information

NPI: 1164642641
Provider Name (Legal Business Name): JODI DEYOUNG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 10/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2907 BLISS CT
PLAINFIELD IL
60586-2833
US

IV. Provider business mailing address

2907 BLISS CT
PLAINFIELD IL
60586-2833
US

V. Phone/Fax

Practice location:
  • Phone: 630-234-0178
  • Fax: 815-609-3050
Mailing address:
  • Phone: 630-234-0178
  • Fax: 815-609-3050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149006185
License Number StateIL

VII. Legacy identifiers

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

# 1
Identifier149006185
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: