Healthcare Provider Details

I. General information

NPI: 1568331742
Provider Name (Legal Business Name): JACQUELYN ARIADNE CARLTON PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2025
Last Update Date: 04/04/2026
Certification Date: 04/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5340 N CLARK ST
CHICAGO IL
60640-2120
US

IV. Provider business mailing address

3354 N PAULINA ST STE 205
CHICAGO IL
60657-1087
US

V. Phone/Fax

Practice location:
  • Phone: 773-696-0485
  • Fax:
Mailing address:
  • Phone: 773-696-0485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.022605
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: