Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TS0200X | School Psychologist | 1848773 | IL |
NPI | 1073039350 |
---|---|
Provider Name | Mrs. Jennifer Ann Mamak |
First Address | Bolingbrook, IL 60490-4510 |
Second Address | Bolingbrook, IL 60490-4510 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/08/2017 |
Last Update Date | 17/08/2017 |