Provider Demographics
NPI:1629507751
Name:DERON, JESSICA VIVIANN (LCPC)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:VIVIANN
Last Name:DERON
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 1:2812 KILBURNE LN APT 204
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-4808
Mailing Address - Country:US
Mailing Address - Phone:630-506-9299
Mailing Address - Fax:
Practice Address - Street 1:404 W BOUGHTON RD STE A
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1898
Practice Address - Country:US
Practice Address - Phone:630-759-4000
Practice Address - Fax:630-759-5220
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-12
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178012473101YP2500X
IL180014528101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty