Provider Demographics
NPI:1891554002
Name:FOUNTAIN, JOHN WESLEY III (MSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WESLEY
Last Name:FOUNTAIN
Suffix:III
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7331 S RHODES AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-1705
Mailing Address - Country:US
Mailing Address - Phone:708-676-9743
Mailing Address - Fax:
Practice Address - Street 1:7331 S RHODES AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-1705
Practice Address - Country:US
Practice Address - Phone:708-676-9743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health