Provider Demographics
NPI:1053755538
Name:SIDDIQI, JENNY M (PSYD)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:M
Last Name:SIDDIQI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 HOLLISTER DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5263
Mailing Address - Country:US
Mailing Address - Phone:847-549-1189
Mailing Address - Fax:847-932-4066
Practice Address - Street 1:1800 HOLLISTER DR
Practice Address - Street 2:SUITE 201
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5263
Practice Address - Country:US
Practice Address - Phone:847-549-1189
Practice Address - Fax:847-932-4066
Is Sole Proprietor?:No
Enumeration Date:2013-04-26
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009384103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical