Healthcare Provider Details

I. General information

NPI: 1477059913
Provider Name (Legal Business Name): CARRIE JAMESON LCPC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 04/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

561 W DIVERSEY PKWY STE 214
CHICAGO IL
60614-1682
US

IV. Provider business mailing address

519 W SURF ST APT 2
CHICAGO IL
60657-6014
US

V. Phone/Fax

Practice location:
  • Phone: 312-371-2646
  • Fax:
Mailing address:
  • Phone: 312-371-2646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CARRIE L JAMESON
Title or Position: OWNER
Credential: LCPC
Phone: 312-371-2646