Healthcare Provider Details

I. General information

NPI: 1235549379
Provider Name (Legal Business Name): JENNIFER GRAY LCPC, CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2014
Last Update Date: 05/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E HURON ST STE 11-100
CHICAGO IL
60611-2968
US

IV. Provider business mailing address

2220 HARTZELL ST
EVANSTON IL
60201-1424
US

V. Phone/Fax

Practice location:
  • Phone: 312-860-0480
  • Fax: 312-926-3709
Mailing address:
  • Phone: 312-860-0480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number27727
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180008877
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: