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General NPI Number Information
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NPI Number | 1609108703
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Entity Type | Individual
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Provider Name | JEREMY TODD BIDWELL PH.D.
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Gender | Male
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Dates
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Enumeration Date | 02/01/2010
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Last Update Date | 12/15/2021
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Provider Practice Location Address
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Address Line | 111 DEAN ST
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City | WOODSTOCK
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State | IL
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Zip | 60098-3220
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Country | US
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Telephone | 815-344-5061
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Fax | 815-344-5072
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Provider Business Mailing Address
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Address Line | 111 DEAN ST
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City | WOODSTOCK
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State | IL
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Zip | 60098-3220
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Country | US
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Telephone | 815-344-5061
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Fax | 815-344-5072
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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 | 071.007831
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 103TP0016X
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Taxonomy Name | Prescribing (Medical) Psychologist
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License Number | 074.000011
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License Number State | IL
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