Provider Demographics
NPI:1871586214
Name:OWENS, JESSE LEE (MA, LCSW)
Entity type:Individual
Prefix:MR
First Name:JESSE
Middle Name:LEE
Last Name:OWENS
Suffix:
Gender:M
Credentials:MA, LCSW
Other - Prefix:MR
Other - First Name:JESSE
Other - Middle Name:LEE
Other - Last Name:OWENS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 84
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60425-0084
Mailing Address - Country:US
Mailing Address - Phone:773-759-2109
Mailing Address - Fax:773-238-5902
Practice Address - Street 1:15475 S PARK AVE STE 102
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-1378
Practice Address - Country:US
Practice Address - Phone:312-480-5775
Practice Address - Fax:312-436-5208
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041S0200X
IL149-0074401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01634638OtherBCBS OF ILLINOIS
IL810323000OtherMAGELLAN BEHAVIORAL HEALTH
IL243340Medicare PIN