MEDICARE: JESSICA WEISBACH, LLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1881291789
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JESSICA WEISBACH, LLC

Provider Business Mailing Address
First Line	:	2257 N KEDZIE BLVD APT 3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-2561
Country	:	US
Telephone Number	:	847-971-4314
Fax Number	:

Provider Business Practice Location Address
First Line	:	2257 N KEDZIE BLVD APT 3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-2561
Country	:	US
Telephone Number	:	847-971-4314
Fax Number	:

Authorized Official
Title or Position	:	OWNER/MENTAL HEALTH THERAPIST
Name	:	MS. JESSICA WEISBACH
Credential	:	LCSW
Telephone Number	:	847-971-4314

Provider Enumeration Date	:	10/04/2020
Last Update Date	:	10/04/2020

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