Provider Demographics
NPI:1073358396
Name:MOEN, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MOEN
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 1:2009 N 73RD AVE APT 2S
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60707-3174
Mailing Address - Country:US
Mailing Address - Phone:708-707-2152
Mailing Address - Fax:
Practice Address - Street 1:126 E CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2014
Practice Address - Country:US
Practice Address - Phone:312-787-8425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health