Provider Demographics
NPI:1669099727
Name:REILLY, JORDAN NICOLE (MACP, QMHP)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:NICOLE
Last Name:REILLY
Suffix:
Gender:F
Credentials:MACP, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 N HALSTED ST APT 26
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-9161
Mailing Address - Country:US
Mailing Address - Phone:704-681-3377
Mailing Address - Fax:
Practice Address - Street 1:2310 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1131
Practice Address - Country:US
Practice Address - Phone:312-602-1467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor