Provider Demographics
NPI:1164971909
Name:BANNER - HUBBARD, JASMINE (LCPC)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:BANNER - HUBBARD
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 1:800 E 55TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4906
Mailing Address - Country:US
Mailing Address - Phone:708-724-9631
Mailing Address - Fax:
Practice Address - Street 1:800 E 55TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4906
Practice Address - Country:US
Practice Address - Phone:708-724-9631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180010414101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional