Provider Demographics
NPI:1992912703
Name:JILES, TYWANDA (MFT-IT,)
Entity type:Individual
Prefix:DR
First Name:TYWANDA
Middle Name:
Last Name:JILES
Suffix:
Gender:F
Credentials:MFT-IT,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14540 S MARQUETTE AVE
Mailing Address - Street 2:
Mailing Address - City:BURNHAM
Mailing Address - State:IL
Mailing Address - Zip Code:60633-2007
Mailing Address - Country:US
Mailing Address - Phone:773-710-6897
Mailing Address - Fax:
Practice Address - Street 1:14540 S MARQUETTE AVE
Practice Address - Street 2:
Practice Address - City:BURNHAM
Practice Address - State:IL
Practice Address - Zip Code:60633-2007
Practice Address - Country:US
Practice Address - Phone:737-710-6897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
WI1130-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1130-228OtherMARRIGE AND FAMILY THERAPIST