Provider Demographics
NPI:1902049653
Name:SULLIVAN, JENNIFER RENEE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENEE
Last Name:SULLIVAN
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 1:4634 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:HEYWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:61745-9462
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2416 E WASHINGTON ST
Practice Address - Street 2:SUITE G
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-4472
Practice Address - Country:US
Practice Address - Phone:309-662-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-10
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0-07-2352103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst