Healthcare Provider Details

I. General information

NPI: 1972830669
Provider Name (Legal Business Name): SIMON THOMAS JENCIUS LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2009
Last Update Date: 07/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1786 MOON LAKE BLVD SUITE 104
HOFFMAN ESTATES IL
60169-5029
US

IV. Provider business mailing address

1786 MOON LAKE BLVD SUITE 104
HOFFMAN ESTATES IL
60169-5029
US

V. Phone/Fax

Practice location:
  • Phone: 847-755-8090
  • Fax: 847-843-7393
Mailing address:
  • Phone: 847-755-8090
  • Fax: 847-843-7393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180-007342
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: