Provider Demographics
NPI:1831675693
Name:JONES, MANDISA (LCSW)
Entity Type:Individual
Prefix:
First Name:MANDISA
Middle Name:
Last Name:JONES
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 1:406 E 46TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-4102
Mailing Address - Country:US
Mailing Address - Phone:773-559-2290
Mailing Address - Fax:
Practice Address - Street 1:1136 S DELANO CT W STE B201
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-3734
Practice Address - Country:US
Practice Address - Phone:773-559-2290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-16
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490206781041C0700X
IL150.01571104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker