Healthcare Provider Details

I. General information

NPI: 1073358396
Provider Name (Legal Business Name): JESSICA MOEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2024
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E WOODFIELD RD STE 401
SCHAUMBURG IL
60173-5126
US

IV. Provider business mailing address

2009 N 73RD AVE APT 2S
ELMWOOD PARK IL
60707-3174
US

V. Phone/Fax

Practice location:
  • Phone: 224-269-4551
  • Fax:
Mailing address:
  • Phone: 708-707-2152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: