Provider Demographics
NPI:1043022718
Name:CONNELLY, JAMIE LYNN (LSW)
Entity type:Individual
Prefix:MS
First Name:JAMIE
Middle Name:LYNN
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4745 MAIN ST STE 207
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-1758
Mailing Address - Country:US
Mailing Address - Phone:630-442-1895
Mailing Address - Fax:
Practice Address - Street 1:4745 MAIN ST STE 207
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-1758
Practice Address - Country:US
Practice Address - Phone:630-442-1895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
IL150.116013104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker