Healthcare Provider Details

I. General information

NPI: 1891266391
Provider Name (Legal Business Name): JOSE DE JESUS INIGUEZ PHD, LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2018
Last Update Date: 12/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2755 W ARMITAGE AVE
CHICAGO IL
60647-4244
US

IV. Provider business mailing address

4043 S RICHMOND ST
CHICAGO IL
60632-1831
US

V. Phone/Fax

Practice location:
  • Phone: 773-252-3100
  • Fax:
Mailing address:
  • Phone: 773-491-9815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.011950
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: