Provider Demographics
NPI:1952880924
Name:UPTON, JOELLA LOUISE
Entity Type:Individual
Prefix:
First Name:JOELLA
Middle Name:LOUISE
Last Name:UPTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 CHEKER SQ
Mailing Address - Street 2:
Mailing Address - City:EAST HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-1442
Mailing Address - Country:US
Mailing Address - Phone:708-647-3333
Mailing Address - Fax:708-647-3304
Practice Address - Street 1:1909 CHEKER SQ
Practice Address - Street 2:
Practice Address - City:EAST HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429
Practice Address - Country:US
Practice Address - Phone:708-647-3333
Practice Address - Fax:708-647-3304
Is Sole Proprietor?:No
Enumeration Date:2018-08-10
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL6453101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)