Provider Demographics
NPI:1083768642
Name:JACK, KATHRYN B (LCPC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:B
Last Name:JACK
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 E ROOSEVELT RD STE 205
Mailing Address - Street 2:
Mailing Address - City:WEST CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60185-3901
Mailing Address - Country:US
Mailing Address - Phone:630-779-0972
Mailing Address - Fax:
Practice Address - Street 1:490 E ROOSEVELT RD STE 205
Practice Address - Street 2:
Practice Address - City:WEST CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60185-3901
Practice Address - Country:US
Practice Address - Phone:630-779-0972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180005428101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health