Basic Information
| Provider Information | |||||||||
| NPI: | 1174192132 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | JENNIE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 WHEATON CTR APT 1311 | ||||||||
| Address2: | |||||||||
| City: | WHEATON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601872313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593026543 | ||||||||
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| Practice Location | |||||||||
| Address1: | 32 MAIN ST STE D | ||||||||
| Address2: | |||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600684060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478234444 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2021 | ||||||||
| LastUpdateDate: | 09/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 071.010598 | IL | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 38817 | TX | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.