Provider Demographics
NPI:1790297794
Name:JACQUES, KRISTIANNA E (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KRISTIANNA
Middle Name:E
Last Name:JACQUES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6614 N ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-6400
Mailing Address - Country:US
Mailing Address - Phone:207-776-1703
Mailing Address - Fax:207-776-1703
Practice Address - Street 1:6614 N ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-6400
Practice Address - Country:US
Practice Address - Phone:207-776-1703
Practice Address - Fax:207-776-1703
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490180071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty