Provider Demographics
NPI:1699902080
Name:ANDERSON, JENNIFER L (DDS)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 368
Mailing Address - Street 2:208 N. WALNUT AVE
Mailing Address - City:FORRESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61030
Mailing Address - Country:US
Mailing Address - Phone:815-938-2575
Mailing Address - Fax:815-938-2363
Practice Address - Street 1:208 N. WALNUT AVE
Practice Address - Street 2:
Practice Address - City:FORRESTON
Practice Address - State:IL
Practice Address - Zip Code:61030
Practice Address - Country:US
Practice Address - Phone:815-938-2575
Practice Address - Fax:815-938-2363
Is Sole Proprietor?:No
Enumeration Date:2009-06-12
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190285371223G0001X
WI64101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice