Provider Demographics
NPI:1841796992
Name:DAVIS-EL, JERRY (CADC)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:DAVIS-EL
Suffix:
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 S JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-5603
Mailing Address - Country:US
Mailing Address - Phone:312-441-9009
Mailing Address - Fax:312-441-9019
Practice Address - Street 1:33 E 114TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-4921
Practice Address - Country:US
Practice Address - Phone:773-660-4630
Practice Address - Fax:773-660-4650
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL29962101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)