Provider Demographics
NPI:1760500052
Name:IVERSON, JEROME DOUGLAS (LCPC)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:DOUGLAS
Last Name:IVERSON
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3375 N ARLINGTON HEIGHTS RD STE F
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-7701
Mailing Address - Country:US
Mailing Address - Phone:847-577-4530
Mailing Address - Fax:
Practice Address - Street 1:3375 N ARLINGTON HEIGHTS RD STE F
Practice Address - Street 2:
Practice Address - City:ARLINGTON HTS
Practice Address - State:IL
Practice Address - Zip Code:60004-7701
Practice Address - Country:US
Practice Address - Phone:847-577-4530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional