Healthcare Provider Details

I. General information

NPI: 1225432982
Provider Name (Legal Business Name): JANE DILLINGHAM M.A., LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2014
Last Update Date: 10/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4980 N MARINE DR APT 434
CHICAGO IL
60640-7823
US

IV. Provider business mailing address

4980 N MARINE DR APT 434
CHICAGO IL
60640-7823
US

V. Phone/Fax

Practice location:
  • Phone: 773-989-9224
  • Fax:
Mailing address:
  • Phone: 773-989-9224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.002546
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.002546
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: