Healthcare Provider Details

I. General information

NPI: 1114014107
Provider Name (Legal Business Name): JENNIFER WANG L.C.S.W
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 03/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

561 W DIVERSEY PKWY SUITE 210
CHICAGO IL
60614-6068
US

IV. Provider business mailing address

561 W DIVERSEY PKWY SUITE 210
CHICAGO IL
60614-6068
US

V. Phone/Fax

Practice location:
  • Phone: 773-425-4064
  • Fax: 773-244-9622
Mailing address:
  • Phone: 773-425-4064
  • Fax: 773-244-9622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149010593
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: