Provider Demographics
NPI:1063818649
Name:BOUSEK, JACKIE LYNN (ATR, LCPC)
Entity Type:Individual
Prefix:MS
First Name:JACKIE
Middle Name:LYNN
Last Name:BOUSEK
Suffix:
Gender:F
Credentials:ATR, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2302 W NORTH AVE
Mailing Address - Street 2:#1E
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-6260
Mailing Address - Country:US
Mailing Address - Phone:708-320-8992
Mailing Address - Fax:
Practice Address - Street 1:2302 W NORTH AVE
Practice Address - Street 2:#1E
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-6260
Practice Address - Country:US
Practice Address - Phone:708-320-8992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-10
Last Update Date:2016-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.009703101YP2500X
IL180010087101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional