Provider Demographics
NPI:1023674769
Name:WHITE, JENNA ELIZABETH
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:ELIZABETH
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 W MONTROSE AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-1674
Mailing Address - Country:US
Mailing Address - Phone:773-655-3241
Mailing Address - Fax:
Practice Address - Street 1:2650 W MONTROSE AVE STE 302
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-1674
Practice Address - Country:US
Practice Address - Phone:773-655-3241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180012181101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty