=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306630918
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER TINO LSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2025
-----------------------------------------------------
Last Update Date | 11/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 199 W RAND RD STE 203
-----------------------------------------------------
City | MOUNT PROSPECT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60056-1157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-618-5450
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 228 N PRAIRIE AVE
-----------------------------------------------------
City | MUNDELEIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60060-2128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-723-6296
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 150.107437
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------