=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124246871
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEAN K TIERNAN LCSW, CADC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2007
-----------------------------------------------------
Last Update Date | 10/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 ROHLWING RD
-----------------------------------------------------
City | ELK GROVE VILLAGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60007-3217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-524-8800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 115
-----------------------------------------------------
City | SHINGLETON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49884-0115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-894-4919
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149.017623
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801108606
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------