Provider Demographics
NPI:1215795000
Name:BLACK, JACQUES D (LSW)
Entity type:Individual
Prefix:
First Name:JACQUES
Middle Name:D
Last Name:BLACK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 E EVERGREEN DR APT 101
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60074-8712
Mailing Address - Country:US
Mailing Address - Phone:574-315-0546
Mailing Address - Fax:
Practice Address - Street 1:1525 E 53RD ST STE 901
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4572
Practice Address - Country:US
Practice Address - Phone:773-234-0644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional