Provider Demographics
NPI:1447880513
Name:JORDAN-LAKE, JULIA
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:JORDAN-LAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 N CUYLER AVE APT 2R
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2378
Mailing Address - Country:US
Mailing Address - Phone:615-975-2774
Mailing Address - Fax:
Practice Address - Street 1:7421 MADISON ST
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-1575
Practice Address - Country:US
Practice Address - Phone:615-975-2774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-17
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.015637101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health