Provider Demographics
NPI:1528736832
Name:JENDUSA, MELISSA N (CADC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:N
Last Name:JENDUSA
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 MEDINA ST
Mailing Address - Street 2:
Mailing Address - City:DURAND
Mailing Address - State:IL
Mailing Address - Zip Code:61024-8925
Mailing Address - Country:US
Mailing Address - Phone:815-742-1816
Mailing Address - Fax:
Practice Address - Street 1:5702 ELAINE DR STE 108
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2458
Practice Address - Country:US
Practice Address - Phone:779-901-0792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL33244101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)