Provider Demographics
NPI:1669127601
Name:PENDERGAST, JESSICA (LSW)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:PENDERGAST
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4326 NUTMEG LN APT 117
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-1799
Mailing Address - Country:US
Mailing Address - Phone:312-505-1056
Mailing Address - Fax:
Practice Address - Street 1:777 W ARMY TRAIL BLVD FL 2
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-3163
Practice Address - Country:US
Practice Address - Phone:630-693-7934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.105509104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker