Provider Demographics
NPI:1437647724
Name:COORS, JESSICA GRACE (LCPC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:GRACE
Last Name:COORS
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 1:2930 N SHERIDAN RD APT 1807
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5977
Mailing Address - Country:US
Mailing Address - Phone:480-239-8934
Mailing Address - Fax:
Practice Address - Street 1:2930 N SHERIDAN RD APT 1807
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5977
Practice Address - Country:US
Practice Address - Phone:480-239-8934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-23
Last Update Date:2024-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008179101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty