Provider Demographics
NPI:1225121353
Name:MALLY, JENNIFER (LCPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MALLY
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 1:1227 N HONORE ST
Mailing Address - Street 2:3
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3119
Mailing Address - Country:US
Mailing Address - Phone:773-540-9261
Mailing Address - Fax:773-540-9261
Practice Address - Street 1:1227 N HONORE ST
Practice Address - Street 2:3
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-3119
Practice Address - Country:US
Practice Address - Phone:773-540-9261
Practice Address - Fax:773-540-9261
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180004361101YP2500X
KSLCPC03478101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional