Provider Demographics
NPI:1649738550
Name:BACKUS, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BACKUS
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 1:1209 W DIVERSEY PKWY UNIT G-2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1201
Mailing Address - Country:US
Mailing Address - Phone:802-922-4860
Mailing Address - Fax:
Practice Address - Street 1:1209 W DIVERSEY PKWY UNIT G-2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1201
Practice Address - Country:US
Practice Address - Phone:802-922-4860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-10
Last Update Date:2022-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
IL178.018663101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician