=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194443424
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NELSON JENIG LSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2022
-----------------------------------------------------
Last Update Date | 08/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 533 W NORTH AVE STE LL80
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60126-2135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-384-9499
-----------------------------------------------------
Fax | 630-324-4606
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1447 W LEXINGTON ST APT 3F
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60607-4031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-212-2341
-----------------------------------------------------
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 | 150105969
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------