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General NPI Number Information
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NPI Number | 1245048834
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Entity Type | Individual
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Provider Name | JENNA GIDMAN-DUTTA
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Gender | Female
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Dates
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Enumeration Date | 12/27/2024
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Last Update Date | 12/27/2024
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Provider Practice Location Address
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Address Line | 1315 BUTTERFIELD RD STE 208
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City | DOWNERS GROVE
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State | IL
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Zip | 60515-5602
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Country | US
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Telephone | 630-441-4415
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Fax |
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Provider Business Mailing Address
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Address Line | 4315 CHELSEA MANOR CIR
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City | AURORA
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State | IL
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Zip | 60504-3275
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Country | US
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Telephone | 574-286-8375
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071011335
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License Number State | IL
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