Provider Demographics
NPI:1356744171
Name:LUCE, JEREMY (MA, PSYD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:LUCE
Suffix:
Gender:M
Credentials:MA, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2451 N LINCOLN AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1509
Mailing Address - Country:US
Mailing Address - Phone:708-320-9694
Mailing Address - Fax:
Practice Address - Street 1:2451 N LINCOLN AVE STE 206
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1509
Practice Address - Country:US
Practice Address - Phone:708-320-9694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL071.0100007103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL071.0100007OtherSTATE LICENSE