Healthcare Provider Details

I. General information

NPI: 1700377470
Provider Name (Legal Business Name): ASHLEY JESSEN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 05/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1633 N CLEVELAND AVE
CHICAGO IL
60614-5685
US

IV. Provider business mailing address

962 W MONTANA ST
CHICAGO IL
60614-2409
US

V. Phone/Fax

Practice location:
  • Phone: 847-910-5519
  • Fax:
Mailing address:
  • Phone: 847-910-5519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.008492
License Number StateIL

VIII. Authorized Official

Name: ASHLEY JESSEN
Title or Position: OWNER, THERAPIST
Credential: LCPC
Phone: 847-910-5519