Provider Demographics
NPI:1487898870
Name:DIERS, JENNIFER ANN (LPN, MHP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANN
Last Name:DIERS
Suffix:
Gender:F
Credentials:LPN, MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 PYRAMID LN
Mailing Address - Street 2:
Mailing Address - City:CREAL SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:62922-3852
Mailing Address - Country:US
Mailing Address - Phone:217-725-4823
Mailing Address - Fax:
Practice Address - Street 1:408 E VINE ST
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:IL
Practice Address - Zip Code:62995-1612
Practice Address - Country:US
Practice Address - Phone:618-658-2611
Practice Address - Fax:618-658-2501
Is Sole Proprietor?:No
Enumeration Date:2009-04-29
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IL043024214164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse