Healthcare Provider Details

I. General information

NPI: 1639645260
Provider Name (Legal Business Name): JESUS EMMANUEL REYES LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2018
Last Update Date: 10/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18555 CARRIAGE LN
LANSING IL
60438-2535
US

IV. Provider business mailing address

18555 CARRIAGE LN
LANSING IL
60438-2535
US

V. Phone/Fax

Practice location:
  • Phone: 708-220-2175
  • Fax:
Mailing address:
  • Phone: 708-220-2175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.004510
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: