=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417294927
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNA ANN PRONGER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2013
-----------------------------------------------------
Last Update Date | 09/24/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4201 W 93RD ST
-----------------------------------------------------
City | OAK LAWN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60453-1998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-423-0150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10360 S 84TH AVE
-----------------------------------------------------
City | PALOS HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60465-1702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-983-3101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------