Provider Demographics
NPI:1588725873
Name:HERBSTMAN, JACQUELINE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:HERBSTMAN
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 1:3133 N LAKEWOOD AVE
Mailing Address - Street 2:APT. 4F
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-9459
Mailing Address - Country:US
Mailing Address - Phone:312-307-9887
Mailing Address - Fax:
Practice Address - Street 1:1770 W BERTEAU AVE
Practice Address - Street 2:SUITE 302A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-1849
Practice Address - Country:US
Practice Address - Phone:312-307-9887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2124311041C0700X
IL1490138101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical