=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346482494
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNA MICHELLE COLLINS-REED LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2009
-----------------------------------------------------
Last Update Date | 10/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7 GLEN ED PROFESSIONAL PARK
-----------------------------------------------------
City | GLEN CARBON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62034-3333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-806-4205
-----------------------------------------------------
Fax | 618-288-7398
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6805 IL 162 SUITE 201
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-288-5019
-----------------------------------------------------
Fax | 618-288-5059
-----------------------------------------------------
=====================================================
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 | 149012819
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------