1255925434 NPI number — JENNEA AILEEN KLINGENBERG PSYD

Table of content: JENNEA AILEEN KLINGENBERG PSYD (NPI 1255925434)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255925434 NPI number — JENNEA AILEEN KLINGENBERG PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLINGENBERG
Provider First Name:
JENNEA
Provider Middle Name:
AILEEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BIVENS
Provider Other First Name:
JENNEA
Provider Other Middle Name:
AILEEN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PSYD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1255925434
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1709 TRAILS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
URBANA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61802-7826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-842-9520
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1709 TRAILS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
URBANA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61802-7826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-842-9520
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/27/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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