Provider Demographics
NPI:1972990190
Name:GOURGUECHON, JACQUES A (LPC)
Entity Type:Individual
Prefix:MR
First Name:JACQUES
Middle Name:A
Last Name:GOURGUECHON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1454 W FARRAGUT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2104
Mailing Address - Country:US
Mailing Address - Phone:312-203-9211
Mailing Address - Fax:
Practice Address - Street 1:1454 W FARRAGUT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2104
Practice Address - Country:US
Practice Address - Phone:312-203-9211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-26
Last Update Date:2015-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.010830101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional