Provider Demographics
NPI:1982473161
Name:BORGE, JACOB RYAN (MA, LPC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RYAN
Last Name:BORGE
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4431 N RACINE AVE APT 3S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5661
Mailing Address - Country:US
Mailing Address - Phone:701-205-9327
Mailing Address - Fax:
Practice Address - Street 1:3100 DUNDEE RD STE 101
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2462
Practice Address - Country:US
Practice Address - Phone:847-919-9096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.019722101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health