Healthcare Provider Details

I. General information

NPI: 1326312596
Provider Name (Legal Business Name): JESSICA HACKMAN WEIDEL LCPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2012
Last Update Date: 03/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

553 W OAKDALE AVE #204
CHICAGO IL
60657-5753
US

IV. Provider business mailing address

553 W OAKDALE AVE #204
CHICAGO IL
60657-5753
US

V. Phone/Fax

Practice location:
  • Phone: 513-310-5423
  • Fax:
Mailing address:
  • Phone: 513-310-5423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.007480
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: