MEDICARE: MS. CAROL DIANNE JENNINGS LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01634922	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1265577662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CAROL DIANNE JENNINGS LCPC

Provider Business Mailing Address
First Line	:	708 CHURCH STREET
Second Line	:	SUITE 245
City	:	EVANSTON
State	:	IL
Zip	:	60201-3840
Country	:	US
Telephone Number	:	847-492-9288
Fax Number	:

Provider Business Practice Location Address
First Line	:	708 CHURCH STREET
Second Line	:	SUITE 245
City	:	EVANSTON
State	:	IL
Zip	:	60201-3840
Country	:	US
Telephone Number	:	847-492-9288
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	07/08/2007

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