Provider Demographics
NPI:1114014107
Name:WANG, JENNIFER (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WANG
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 1:561 W DIVERSEY PKWY
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-6068
Mailing Address - Country:US
Mailing Address - Phone:773-425-4064
Mailing Address - Fax:773-244-9622
Practice Address - Street 1:561 W DIVERSEY PKWY
Practice Address - Street 2:SUITE 210
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-6068
Practice Address - Country:US
Practice Address - Phone:773-425-4064
Practice Address - Fax:773-244-9622
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490105931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical