Healthcare Provider Details

I. General information

NPI: 1821444506
Provider Name (Legal Business Name): JESSICA URBAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2016
Last Update Date: 11/24/2022
Certification Date: 11/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

391 NORTH AVE
ANTIOCH IL
60002-3204
US

IV. Provider business mailing address

PO BOX 844
WAUCONDA IL
60084-0844
US

V. Phone/Fax

Practice location:
  • Phone: 224-678-1710
  • Fax:
Mailing address:
  • Phone: 224-678-1710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5951
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149016169
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: