Provider Demographics
NPI:1932789013
Name:TYLER, JESSICA (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:TYLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10609 S CENTRAL PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-3203
Mailing Address - Country:US
Mailing Address - Phone:513-633-2800
Mailing Address - Fax:
Practice Address - Street 1:10609 S CENTRAL PARK AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-3203
Practice Address - Country:US
Practice Address - Phone:513-633-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-21-56199103K00000X
IL1490221121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst