Healthcare Provider Details

I. General information

NPI: 1023651114
Provider Name (Legal Business Name): JENELLE NICOLE THOMAS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2019
Last Update Date: 04/04/2021
Certification Date: 04/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1142 W MADISON ST
CHICAGO IL
60607-2191
US

IV. Provider business mailing address

15255 S 94TH AVE STE 500 SUITE 500 - #365
ORLAND PARK IL
60462
US

V. Phone/Fax

Practice location:
  • Phone: 312-324-4502
  • Fax:
Mailing address:
  • Phone: 773-273-6365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.102988
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: