MEDICARE: JASA PERRY LCPC

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	180015424	IL
2	101YP2500X	Professional Counselor	39005742A	IN
3	101YM0800X	Mental Health Counselor	180015424	IL
4	101Y00000X	Counselor	39005742A	IN
5	101YM0800X	Mental Health Counselor	39005742A	IN
6	101Y00000X	Counselor	180015424	IL

General Provider Information

NPI Number	:	1407321458
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASA PERRY LCPC

Provider Business Mailing Address
First Line	:	16000 VAN DRUNEN RD
Second Line	:
City	:	SOUTH HOLLAND
State	:	IL
Zip	:	60473-1242
Country	:	US
Telephone Number	:	312-650-9413
Fax Number	:	312-270-0459

Provider Business Practice Location Address
First Line	:	16000 VAN DRUNEN RD
Second Line	:
City	:	SOUTH HOLLAND
State	:	IL
Zip	:	60473-1242
Country	:	US
Telephone Number	:	312-650-9413
Fax Number	:	312-270-0459

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

Provider Enumeration Date	:	10/05/2018
Last Update Date	:	04/19/2026

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