Healthcare Provider Details

I. General information

NPI: 1649917345
Provider Name (Legal Business Name): JISELLE ROMAN LCPC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2022
Last Update Date: 11/04/2023
Certification Date: 11/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10720 PRINCESS AVE
CHICAGO RIDGE IL
60415-2139
US

IV. Provider business mailing address

9631 S CICERO AVE # 1459
OAK LAWN IL
60453-3137
US

V. Phone/Fax

Practice location:
  • Phone: 773-627-7914
  • Fax: 708-575-6527
Mailing address:
  • Phone: 773-627-7914
  • Fax: 708-575-6527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JISELLE ROMAN
Title or Position: LICENSED CLINICAL PROFESSIONAL COUN
Credential: LCPC
Phone: 773-627-7914