Healthcare Provider Details

I. General information

NPI: 1801623590
Provider Name (Legal Business Name): JESSE BUSS MSW, LSW, QMHP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2302 MORELAND BLVD
CHAMPAIGN IL
61822-1398
US

IV. Provider business mailing address

2521 LEEPER DR. UNIT A
CHAMPAIGN IL
61822
US

V. Phone/Fax

Practice location:
  • Phone: 217-356-7576
  • Fax:
Mailing address:
  • Phone: 815-323-9944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150113732
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: