Provider Demographics
NPI:1558468025
Name:GUTIERREZ, JEANNIE M (PHD)
Entity type:Individual
Prefix:DR
First Name:JEANNIE
Middle Name:M
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 CHICAGO AVE
Mailing Address - Street 2:#5
Mailing Address - City:EVANSTON
Mailing Address - State:ID
Mailing Address - Zip Code:60201
Mailing Address - Country:US
Mailing Address - Phone:847-687-9055
Mailing Address - Fax:
Practice Address - Street 1:1604 CHICAGO AVE
Practice Address - Street 2:#5
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201
Practice Address - Country:US
Practice Address - Phone:847-687-9055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103G00000X, 103TC0700X, 103TC2200X, 103TM1800X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist