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NPI Code Detail

MEDICARE: JORDAN SEVILLE HENDERSON LPC

MEDICARE: JORDAN SEVILLE HENDERSON LPC
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
1101YM0800XMental Health Counselor178.018592IL

General Provider Information

NPI Number : 1811759244
Entity Type Code : Individual
Provider Name (Legal Business Name) : JORDAN SEVILLE HENDERSON LPC
Provider Business Mailing Address
First Line : 5858 W FULLERTON AVE APT 205
Second Line :
City : CHICAGO
State : IL
Zip : 60639-2362
Country : US
Telephone Number : 773-677-6349
Fax Number :
Provider Business Practice Location Address
First Line : 1105 S WESTERN AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60612-4146
Country : US
Telephone Number : 773-677-6349
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/30/2024
Last Update Date : 01/30/2024

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Directions to “ JORDAN SEVILLE HENDERSON LPC” Practice Location

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