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General NPI Number Information
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NPI Number | 1215795000
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Entity Type | Individual
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Provider Name | JACQUES D BLACK LSW
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Gender | Female
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Dates
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Enumeration Date | 03/07/2024
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 1525 E 53RD ST STE 901
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City | CHICAGO
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State | IL
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Zip | 60615-4572
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Country | US
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Telephone | 773-234-0644
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Fax |
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Provider Business Mailing Address
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Address Line | 1403 E EVERGREEN DR APT 101
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City | PALATINE
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State | IL
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Zip | 60074-8712
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Country | US
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Telephone | 574-315-0546
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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