=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770109720
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JENNIFER PALMER PSYD AND ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2020
-----------------------------------------------------
Last Update Date | 02/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6160 N CICERO AVE STE 302
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60646-4331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-736-2926
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1628 W SHERWIN AVE APT 502
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60626-1983
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-736-2926
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCHOLOGIST / OWNER
-----------------------------------------------------
Name | DR. JENNIFER PALMER
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 312-723-2926
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------