Provider Demographics
NPI:1417254004
Name:REYNOLDS, JALISSA (LCPC)
Entity type:Individual
Prefix:MRS
First Name:JALISSA
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:JALISSA
Other - Middle Name:
Other - Last Name:SHELBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:631 N CARROLL PKWY APT 209
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60425-1161
Mailing Address - Country:US
Mailing Address - Phone:708-637-6760
Mailing Address - Fax:
Practice Address - Street 1:9631 S CICERO AVE # 1073
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-3137
Practice Address - Country:US
Practice Address - Phone:708-637-6760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-17
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IL180014119101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty