Provider Demographics
NPI:1790228930
Name:BUTCHER, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BUTCHER
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 1:2601 W MARQUETTE RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-1817
Mailing Address - Country:US
Mailing Address - Phone:773-565-2564
Mailing Address - Fax:773-565-2570
Practice Address - Street 1:2601 W MARQUETTE RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-1817
Practice Address - Country:US
Practice Address - Phone:773-565-2564
Practice Address - Fax:773-565-2570
Is Sole Proprietor?:No
Enumeration Date:2016-11-21
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490190741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL640701Medicare PIN