=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417769092
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE JELLYBEAN COLLECTIVE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2025
-----------------------------------------------------
Last Update Date | 01/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 65 S. RANDALL RD. UNIT 113
-----------------------------------------------------
City | NORTH AURORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-406-9506
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 472 N SUGAR GROVE PKWY STE F328
-----------------------------------------------------
City | SUGAR GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60554-8107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JESSICA M. GRAYER-BRUMFIELD
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 708-359-0983
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------