Provider Demographics
NPI:1790217966
Name:JESSEN, ASHLEY
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:JESSEN
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 1:962 W MONTANA ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2409
Mailing Address - Country:US
Mailing Address - Phone:847-910-5519
Mailing Address - Fax:
Practice Address - Street 1:1200 N. ASHLAND SUITE 401C
Practice Address - Street 2:LOTUS CENTER
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622
Practice Address - Country:US
Practice Address - Phone:773-850-2295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008492101Y00000X, 101YM0800X, 101YP2500X, 101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool