Provider Demographics
NPI:1962993857
Name:BOEREMA, JORDAN (LCPC, ATR)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BOEREMA
Suffix:
Gender:F
Credentials:LCPC, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4235 N KEDZIE AVE APT 3F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-2471
Mailing Address - Country:US
Mailing Address - Phone:847-721-2910
Mailing Address - Fax:
Practice Address - Street 1:2500 W BRADLEY PL STE 100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-4716
Practice Address - Country:US
Practice Address - Phone:773-649-0787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180011342101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional