Provider Demographics
NPI:1316281603
Name:ANDERSON, JACQUELINE RENEE (PHD, LCSW)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:RENEE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7622 S PERRY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-1026
Mailing Address - Country:US
Mailing Address - Phone:773-454-3768
Mailing Address - Fax:
Practice Address - Street 1:840 W IRVING PARK RD STE 302
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3011
Practice Address - Country:US
Practice Address - Phone:773-659-9207
Practice Address - Fax:773-799-8824
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0093331041C0700X
IL1490093331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical