Basic Information
| Provider Information | |||||||||
| NPI: | 1528425196 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENS | ||||||||
| FirstName: | JAELEE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | MSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FORTNER | ||||||||
| OtherFirstName: | JAELEE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 902 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WEST FRANKFORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628962210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189376483 | ||||||||
| FaxNumber: | 6189371440 | ||||||||
| Practice Location | |||||||||
| Address1: | 403 MUNICIPAL DR | ||||||||
| Address2: | |||||||||
| City: | CARTERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629182042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8556083560 | ||||||||
| FaxNumber: | 6189569349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2016 | ||||||||
| LastUpdateDate: | 06/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.