Healthcare Provider Details

I. General information

NPI: 1245977578
Provider Name (Legal Business Name): NERISSA TUCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2022
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1142 W MADISON ST STE 302
CHICAGO IL
60607-2191
US

IV. Provider business mailing address

1326 S MICHIGAN AVE APT 2011
CHICAGO IL
60605-3525
US

V. Phone/Fax

Practice location:
  • Phone: 312-324-4502
  • Fax:
Mailing address:
  • Phone: 704-965-3954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.018038
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: