Provider Demographics
NPI:1255505301
Name:JONES, WAYNE ALLEN (LCPC, MA)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:ALLEN
Last Name:JONES
Suffix:
Gender:M
Credentials:LCPC, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 N ASHLAND AVE
Mailing Address - Street 2:1R
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3935
Mailing Address - Country:US
Mailing Address - Phone:773-793-4095
Mailing Address - Fax:
Practice Address - Street 1:621 PLAINFIELD RD
Practice Address - Street 2:110
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-5343
Practice Address - Country:US
Practice Address - Phone:773-793-4095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-19
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007101101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid