Provider Demographics
NPI:1821483124
Name:AVILA, JENNIFER (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:AVILA
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 1:2455 W OHIO ST
Mailing Address - Street 2:UNIT 16W
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-1298
Mailing Address - Country:US
Mailing Address - Phone:312-402-0709
Mailing Address - Fax:312-770-2557
Practice Address - Street 1:1127 N OAKLEY BLVD
Practice Address - Street 2:3RD FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-3507
Practice Address - Country:US
Practice Address - Phone:312-770-2317
Practice Address - Fax:312-770-2557
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-02
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490174831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical