Provider Demographics
NPI:1205172681
Name:BLACK, JESSICA L (LCPC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:BLACK
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LORRAINE
Other - Last Name:APPLETON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:1525 E 53RD ST STE 901
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4572
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1525 E 53RD ST STE 901
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4572
Practice Address - Country:US
Practice Address - Phone:773-234-1839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-12
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.009600101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional