Provider Demographics
NPI:1487964003
Name:GLEASON, JENNIFER L (MA)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:L
Last Name:GLEASON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 W PARK ST APT 7
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-1651
Mailing Address - Country:US
Mailing Address - Phone:630-306-2804
Mailing Address - Fax:
Practice Address - Street 1:1801 FOX DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7236
Practice Address - Country:US
Practice Address - Phone:217-398-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-16
Last Update Date:2010-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor