Provider Demographics
NPI:1316761836
Name:RIESEN, JESSICA LYNN (LCPC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:RIESEN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 W LELAND AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-6615
Mailing Address - Country:US
Mailing Address - Phone:419-708-8178
Mailing Address - Fax:
Practice Address - Street 1:931 W LELAND AVE APT 202
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-6615
Practice Address - Country:US
Practice Address - Phone:419-708-8178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.016465101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health