Provider Demographics
NPI:1619313988
Name:WALTZ, JESSE PATRICK (MAED, LMFT)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:PATRICK
Last Name:WALTZ
Suffix:
Gender:M
Credentials:MAED, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 204
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-0204
Mailing Address - Country:US
Mailing Address - Phone:270-312-7752
Mailing Address - Fax:
Practice Address - Street 1:750 SHORELINE DR STE 150
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-6201
Practice Address - Country:US
Practice Address - Phone:708-202-8387
Practice Address - Fax:630-585-1956
Is Sole Proprietor?:No
Enumeration Date:2013-05-14
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY104021106H00000X
IL166.001334106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist