Provider Demographics
NPI:1235549379
Name:GRAY, JENNIFER (LCPC, CADC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:LCPC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 HARTZELL ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1424
Mailing Address - Country:US
Mailing Address - Phone:312-860-0480
Mailing Address - Fax:
Practice Address - Street 1:201 E HURON ST STE 11-100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2968
Practice Address - Country:US
Practice Address - Phone:312-860-0480
Practice Address - Fax:312-926-3709
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-29
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL27727101YA0400X
IL180008877101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)