Provider Demographics
NPI:1639261688
Name:SHERACK, KELLY JANE (PHD, MA)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:JANE
Last Name:SHERACK
Suffix:
Gender:F
Credentials:PHD, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2656 W MONTROSE AVE
Mailing Address - Street 2:SUITE #106
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-1559
Mailing Address - Country:US
Mailing Address - Phone:773-415-7147
Mailing Address - Fax:773-409-7157
Practice Address - Street 1:2656 W MONTROSE AVE
Practice Address - Street 2:SUITE #106
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-1559
Practice Address - Country:US
Practice Address - Phone:773-415-7147
Practice Address - Fax:773-409-7157
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling