Provider Demographics
NPI:1124065602
Name:GEORGEN, JEANETTE W (MA, LCPC, ATR)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:W
Last Name:GEORGEN
Suffix:
Gender:F
Credentials:MA, LCPC, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10314 LINCOLN TRL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-1801
Mailing Address - Country:US
Mailing Address - Phone:618-394-8952
Mailing Address - Fax:618-394-8952
Practice Address - Street 1:10314 LINCOLN TRL
Practice Address - Street 2:SUITE 101
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-1801
Practice Address - Country:US
Practice Address - Phone:618-394-8952
Practice Address - Fax:618-394-8952
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
97-084OtherATR