Provider Demographics
NPI:1508910308
Name:WALL, JESSICA DOYLE (AM, LCSW)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:DOYLE
Last Name:WALL
Suffix:
Gender:F
Credentials:AM, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803A N HARLEM AVE
Mailing Address - Street 2:SUITE 2N
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1627
Mailing Address - Country:US
Mailing Address - Phone:708-383-5940
Mailing Address - Fax:708-383-5940
Practice Address - Street 1:803A N HARLEM AVE
Practice Address - Street 2:SUITE 2N
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1627
Practice Address - Country:US
Practice Address - Phone:708-383-5940
Practice Address - Fax:708-383-5940
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01622512OtherBCBS
IL01622512OtherBCBS