Provider Demographics
NPI:1598425696
Name:JIRSA, TABITHA (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:TABITHA
Middle Name:
Last Name:JIRSA
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 S HIGHLAND AVE APT 763
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-7156
Mailing Address - Country:US
Mailing Address - Phone:708-355-0638
Mailing Address - Fax:
Practice Address - Street 1:15113 W AUSTIN DR
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-1332
Practice Address - Country:US
Practice Address - Phone:331-254-4464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-30
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.017541101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional