=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619479862
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNA HEDGLEN-SMITH PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2018
-----------------------------------------------------
Last Update Date | 03/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5100 N RAVENSWOOD AVE STE 235
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-1752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-945-8357
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2029 N RACINE AVE APT 2B
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-4038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-862-4709
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071009733
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------