MEDICARE: JENNIFER MALLY 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	180004361	IL
2	101YP2500X	Professional Counselor	LCPC03478	KS

General Provider Information

NPI Number	:	1225121353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER MALLY LCPC

Provider Business Mailing Address
First Line	:	1227 N HONORE ST
Second Line	:	3
City	:	CHICAGO
State	:	IL
Zip	:	60622-3119
Country	:	US
Telephone Number	:	773-540-9261
Fax Number	:	773-540-9261

Provider Business Practice Location Address
First Line	:	1227 N HONORE ST
Second Line	:	3
City	:	CHICAGO
State	:	IL
Zip	:	60622-3119
Country	:	US
Telephone Number	:	773-540-9261
Fax Number	:	773-540-9261

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

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	06/27/2023

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