Provider Demographics
NPI:1124896717
Name:BELLEFONTAINE, JACQUELINE ESTELLE (LCSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ESTELLE
Last Name:BELLEFONTAINE
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 1:1451 N MAPLEWOOD AVE APT 1R
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1880
Mailing Address - Country:US
Mailing Address - Phone:630-456-6718
Mailing Address - Fax:
Practice Address - Street 1:1451 N MAPLEWOOD AVE APT 1R
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1880
Practice Address - Country:US
Practice Address - Phone:630-456-6718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-13
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149026409104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker