Healthcare Provider Details

I. General information

NPI: 1104585306
Provider Name (Legal Business Name): JAMESA PRUITT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2021
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6303 N CLARK ST
CHICAGO IL
60660-1203
US

IV. Provider business mailing address

7101 N CICERO AVE STE 202
LINCOLNWOOD IL
60712-2143
US

V. Phone/Fax

Practice location:
  • Phone: 773-293-7599
  • Fax:
Mailing address:
  • Phone: 773-433-6210
  • Fax: 866-744-0950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178017138
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: