Healthcare Provider Details

I. General information

NPI: 1134985567
Provider Name (Legal Business Name): JESSICA EUN CHUNG LPC, ATR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2024
Last Update Date: 02/23/2024
Certification Date: 02/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

661 W LAKE ST STE 2S
CHICAGO IL
60661-1034
US

IV. Provider business mailing address

1530 S STATE ST APT 728
CHICAGO IL
60605-2979
US

V. Phone/Fax

Practice location:
  • Phone: 312-756-0201
  • Fax:
Mailing address:
  • Phone: 312-342-4746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.019237
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number22-360
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: