Provider Demographics
NPI:1649917345
Name:JISELLE ROMAN LCPC PLLC
Entity type:Organization
Organization Name:JISELLE ROMAN LCPC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PROFESSIONAL COUN
Authorized Official - Prefix:
Authorized Official - First Name:JISELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:773-627-7914
Mailing Address - Street 1:9631 S CICERO AVE # 1459
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-3137
Mailing Address - Country:US
Mailing Address - Phone:773-627-7914
Mailing Address - Fax:708-575-6527
Practice Address - Street 1:10720 PRINCESS AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-2139
Practice Address - Country:US
Practice Address - Phone:773-627-7914
Practice Address - Fax:708-575-6527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-16
Last Update Date:2023-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1750703583OtherNPI 1