MEDICARE: JESSICA WARREN

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	178.011426	IL
2	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1912560780
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA WARREN

Provider Business Mailing Address
First Line	:	345 E OHIO ST APT 3206
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-4074
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2451 N LINCOLN AVE STE 203
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-2422
Country	:	US
Telephone Number	:	847-347-1963
Fax Number	:

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

Provider Enumeration Date	:	04/17/2019
Last Update Date	:	04/17/2019

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