Healthcare Provider Details

I. General information

NPI: 1952239139
Provider Name (Legal Business Name): ELISHA DE JESUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4726 N WINTHROP AVE APT 2
CHICAGO IL
60640-5097
US

IV. Provider business mailing address

4726 N WINTHROP AVE APT 2
CHICAGO IL
60640-5097
US

V. Phone/Fax

Practice location:
  • Phone: 312-612-0716
  • Fax:
Mailing address:
  • Phone: 312-612-0716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.017272
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: