=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205491685
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNA PALUMBO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2019
-----------------------------------------------------
Last Update Date | 05/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 N NORTHWEST HWY STE 202
-----------------------------------------------------
City | BARRINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60010-6021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-373-1600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 181 WASHO CT
-----------------------------------------------------
City | LAKE ZURICH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60047-7901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-373-1600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 178013123
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------