Provider Demographics
NPI:1306226287
Name:PICCIUCA, JENNIFER (LCSW CADC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PICCIUCA
Suffix:
Gender:F
Credentials:LCSW CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 CRAWFORD AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4959
Mailing Address - Country:US
Mailing Address - Phone:847-602-3216
Mailing Address - Fax:
Practice Address - Street 1:2530 CRAWFORD AVE STE 207
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4959
Practice Address - Country:US
Practice Address - Phone:847-602-3216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490166961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1306226287OtherNPI 1