Provider Demographics
NPI:1669725701
Name:BIRKS, JACQUELINE ELLEN (MS)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ELLEN
Last Name:BIRKS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 BRAEMAR AVE
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-1301
Mailing Address - Country:US
Mailing Address - Phone:630-961-2053
Mailing Address - Fax:
Practice Address - Street 1:408 BRAEMAR AVE
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-1301
Practice Address - Country:US
Practice Address - Phone:630-961-2053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-25
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.008669101YM0800X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health