MEDICARE: MR. DOMINIQUE ALEXANDER JAMES LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	178.018757	IL

General Provider Information

NPI Number	:	1275220741
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DOMINIQUE ALEXANDER JAMES LPC

Provider Business Mailing Address
First Line	:	5534 N KENMORE AVE APT 507
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-1549
Country	:	US
Telephone Number	:	804-678-8502
Fax Number	:

Provider Business Practice Location Address
First Line	:	53 W JACKSON BLVD STE 231
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60604-3670
Country	:	US
Telephone Number	:	804-678-8502
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2023
Last Update Date	:	04/24/2023

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