Provider Demographics
NPI:1699507020
Name:IVERSON, AMANDA JEAN
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:IVERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4680 N KASSON AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-4230
Mailing Address - Country:US
Mailing Address - Phone:872-302-3396
Mailing Address - Fax:
Practice Address - Street 1:4765 N LINCOLN AVE STE 208
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2077
Practice Address - Country:US
Practice Address - Phone:872-302-3396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist