Provider Demographics
NPI:1518566967
Name:MILGROM, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MILGROM
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 1:1205 W MONTANA ST UNIT 2E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2681
Mailing Address - Country:US
Mailing Address - Phone:847-373-0306
Mailing Address - Fax:
Practice Address - Street 1:1205 W MONTANA ST UNIT 2E
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2681
Practice Address - Country:US
Practice Address - Phone:847-373-0306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-17
Last Update Date:2024-12-18
Deactivation Date:2023-06-07
Deactivation Code:
Reactivation Date:2023-08-01
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty