Provider Demographics
NPI:1700993193
Name:JESSE, KEVIN M (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:M
Last Name:JESSE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9119 S EXCHANGE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-4225
Mailing Address - Country:US
Mailing Address - Phone:773-768-5000
Mailing Address - Fax:
Practice Address - Street 1:2501 W 103RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-1003
Practice Address - Country:US
Practice Address - Phone:773-445-0331
Practice Address - Fax:773-779-2779
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490088841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical