=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437468436
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA E DYREK LCPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2010
-----------------------------------------------------
Last Update Date | 09/25/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 SPINNING WHEEL RD SUITE 422
-----------------------------------------------------
City | HINSDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60521-2914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-272-4966
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18W075 JAMESTOWN LN
-----------------------------------------------------
City | VILLA PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60181-3864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-272-4966
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 180.007616
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------