Provider Demographics
NPI:1134892490
Name:JEMISON, DAX J (LCSW)
Entity type:Individual
Prefix:
First Name:DAX
Middle Name:J
Last Name:JEMISON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6639 S WABASH AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-3034
Mailing Address - Country:US
Mailing Address - Phone:773-383-4067
Mailing Address - Fax:
Practice Address - Street 1:6639 S WABASH AVE UNIT 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-3034
Practice Address - Country:US
Practice Address - Phone:773-383-4067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0217411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical