Provider Demographics
NPI:1861679615
Name:GOSSELIN, JAN EILEEN (LCPC LICENSED CLINIC)
Entity Type:Individual
Prefix:MS
First Name:JAN
Middle Name:EILEEN
Last Name:GOSSELIN
Suffix:
Gender:F
Credentials:LCPC LICENSED CLINIC
Other - Prefix:MS
Other - First Name:JAN
Other - Middle Name:EILEEN
Other - Last Name:PEARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3223 W PARKWAY DR
Mailing Address - Street 2:1-G
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-7237
Mailing Address - Country:US
Mailing Address - Phone:847-337-5797
Mailing Address - Fax:
Practice Address - Street 1:333 SKOKIE BLVD
Practice Address - Street 2:114
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1613
Practice Address - Country:US
Practice Address - Phone:847-337-5797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-23
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180006181101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional