MEDICARE: JESSICA L BLACK LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	180.009600	IL

General Provider Information

NPI Number	:	1205172681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA L BLACK LCPC

Provider Business Mailing Address
First Line	:	1525 E 53RD ST STE 901
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-4572
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1525 E 53RD ST STE 901
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-4572
Country	:	US
Telephone Number	:	773-234-1839
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/12/2012
Last Update Date	:	10/09/2024

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