Provider Demographics
NPI:1639882665
Name:BINGHAM, JYESHA
Entity Type:Individual
Prefix:
First Name:JYESHA
Middle Name:
Last Name:BINGHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 N DEARBORN ST APT 3102
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-5387
Mailing Address - Country:US
Mailing Address - Phone:708-965-0895
Mailing Address - Fax:708-898-0198
Practice Address - Street 1:750 N DEARBORN ST APT 3102
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-5387
Practice Address - Country:US
Practice Address - Phone:708-965-0895
Practice Address - Fax:708-898-0198
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist