1417769092 NPI number — THE JELLYBEAN COLLECTIVE, PLLC

Table of content: (NPI 1417769092)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417769092 NPI number — THE JELLYBEAN COLLECTIVE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE JELLYBEAN COLLECTIVE, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417769092
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
472 N SUGAR GROVE PKWY STE F328
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUGAR GROVE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60554-8107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
65 S. RANDALL RD.
Provider Second Line Business Practice Location Address:
UNIT 113
Provider Business Practice Location Address City Name:
NORTH AURORA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-406-9506
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/22/2025

Additional Information

Authorized Official

Authorized Official Last Name:
GRAYER-BRUMFIELD
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
708-359-0983

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com