Provider Demographics
NPI:1467695148
Name:WICKSTROM, JANCEY LEE (MA, LCSW)
Entity type:Individual
Prefix:MS
First Name:JANCEY
Middle Name:LEE
Last Name:WICKSTROM
Suffix:
Gender:F
Credentials:MA, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 RAVINIA PL
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-3761
Mailing Address - Country:US
Mailing Address - Phone:708-403-7570
Mailing Address - Fax:
Practice Address - Street 1:1800 RAVINIA PL
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3761
Practice Address - Country:US
Practice Address - Phone:708-403-7570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-10
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490134451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical