Healthcare Provider Details

I. General information

NPI: 1437068855
Provider Name (Legal Business Name): JESSICA MACIAS EDS, MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W SECOND ST
MOMENCE IL
60954-1436
US

IV. Provider business mailing address

1388 CLIFTON AVE
BEECHER IL
60401-3442
US

V. Phone/Fax

Practice location:
  • Phone: 815-472-4184
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number2670306
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: