Provider Demographics
NPI:1053483131
Name:GOULD, JESSICA ANNE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:ANNE
Last Name:GOULD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4408 N WINCHESTER AVE
Mailing Address - Street 2:APT 47
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5853
Mailing Address - Country:US
Mailing Address - Phone:312-344-3879
Mailing Address - Fax:
Practice Address - Street 1:1945 W WILSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5255
Practice Address - Country:US
Practice Address - Phone:312-344-3879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2014-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA179941041C0700X
IL1490146451041C0700X
CA250501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical