Healthcare Provider Details

I. General information

NPI: 1154621472
Provider Name (Legal Business Name): JEFFREY WALTER FISH LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2010
Last Update Date: 09/22/2024
Certification Date: 09/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7412 FORDHAM LN
PLAINFIELD IL
60586-4150
US

IV. Provider business mailing address

7412 FORDHAM LN
PLAINFIELD IL
60586-4150
US

V. Phone/Fax

Practice location:
  • Phone: 331-248-7249
  • Fax:
Mailing address:
  • Phone: 331-248-7249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149-014418
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: