Provider Demographics
NPI:1801404348
Name:PHAN, JANINE MARIE (MA, LPC)
Entity Type:Individual
Prefix:
First Name:JANINE
Middle Name:MARIE
Last Name:PHAN
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 W LAWRENCE AVE APT 531
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5007
Mailing Address - Country:US
Mailing Address - Phone:616-821-4241
Mailing Address - Fax:
Practice Address - Street 1:1010 LAKE ST STE 500
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1135
Practice Address - Country:US
Practice Address - Phone:773-665-8052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.015014101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health