Provider Demographics
NPI:1003416124
Name:GENTRY, JESSICA ROSE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:GENTRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N WABASH AVE STE 1400
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3074
Mailing Address - Country:US
Mailing Address - Phone:312-436-1657
Mailing Address - Fax:312-284-4505
Practice Address - Street 1:111 N WABASH AVE STE 1400
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3074
Practice Address - Country:US
Practice Address - Phone:312-436-1657
Practice Address - Fax:312-284-4505
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional