Healthcare Provider Details

I. General information

NPI: 1962969063
Provider Name (Legal Business Name): JEONG HWAN YI LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2019
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 DEMPSTER ST STE 520
PARK RIDGE IL
60068-1130
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 847-720-6464
  • Fax: 847-720-6463
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.018600
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: