Provider Demographics
NPI:1457667776
Name:MARSHALL, JESSICA LEE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LEE
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:LEE
Other - Last Name:BUCKNAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:373 S SCHMALE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-2771
Mailing Address - Country:US
Mailing Address - Phone:630-682-1910
Mailing Address - Fax:630-682-3094
Practice Address - Street 1:336 GUNDERSEN DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188
Practice Address - Country:US
Practice Address - Phone:630-871-2100
Practice Address - Fax:630-588-0824
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-24
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIL#071.009056103TC0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health