Healthcare Provider Details

I. General information

NPI: 1477987915
Provider Name (Legal Business Name): JENNIFER EILEEN MIESZALA LCSW, CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2013
Last Update Date: 06/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 RENAISSANCE DR #101
PARK RIDGE IL
60068-1329
US

IV. Provider business mailing address

1400 RENAISSANCE DR #101
PARK RIDGE IL
60068-1329
US

V. Phone/Fax

Practice location:
  • Phone: 847-963-9639
  • Fax: 312-902-2665
Mailing address:
  • Phone: 847-963-9639
  • Fax: 312-902-2665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20754
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150013502
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149016728
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: