Provider Demographics
NPI:1689951519
Name:KLEIN, JESSE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:
Last Name:KLEIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 W DIVERSEY PKWY STE 207
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1535
Mailing Address - Country:US
Mailing Address - Phone:312-543-7838
Mailing Address - Fax:
Practice Address - Street 1:639 W DIVERSEY PKWY STE 207
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1535
Practice Address - Country:US
Practice Address - Phone:312-543-7838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008124103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent