=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962993857
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORDAN BOEREMA LCPC, ATR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2018
-----------------------------------------------------
Last Update Date | 05/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 W BRADLEY PL STE 100
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60618-4716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-649-0787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4235 N KEDZIE AVE APT 3F
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60618-2471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-721-2910
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180011342
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------