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General NPI Number Information
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NPI Number | 1902495435
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Entity Type | Individual
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Provider Name | JESSICA CARLISLE LCPC, ATR-BC
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Gender | Female
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Dates
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Enumeration Date | 01/11/2021
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Last Update Date | 04/10/2025
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Provider Practice Location Address
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Address Line | 1628 W MONTROSE AVE
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City | CHICAGO
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State | IL
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Zip | 60613-1214
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Country | US
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Telephone | 773-654-1865
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Fax |
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Provider Business Mailing Address
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Address Line | 2043 W BELMONT AVE APT 4
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City | CHICAGO
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State | IL
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Zip | 60618-6796
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Country | US
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Telephone | 815-545-1530
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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 | 178.015285
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180.016034
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License Number State | IL
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