Provider Demographics
NPI:1356810477
Name:JELENEK, JOHANNA
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:JELENEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 N MARSHFIELD AVE APT 2S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3870
Mailing Address - Country:US
Mailing Address - Phone:517-256-1339
Mailing Address - Fax:
Practice Address - Street 1:233 E WACKER DR APT 3901
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-5115
Practice Address - Country:US
Practice Address - Phone:517-256-1339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-19
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.014092101YP2500X
IL180013479101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional