Active NPI
Jaclyn Wallen
- Mental Health Counselor
- Berwyn, IL
National Provider Identifier
1083227995
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Mental Health Counselor
- License
- 180.008708
- Practice address
- 6501 Stanley Ave
Berwyn, IL 60402-3123 - Phone
- (708) 484-7400
- NPI assigned
- Aug 28, 2020
- Last updated
- Aug 28, 2020
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Mental Health Counselor | 101YM0800X | 180.008708 | IL | Primary |
Addresses
Primary practice location
6501 Stanley Ave
Berwyn, IL 60402-3123
Mailing address
5018 W 23Rd St
Cicero, IL 60804-2927
Phone (334) 718-9025
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 180.008708 | IL | MD | Mental Health Counselor |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Youth Crossroads, Inc. | Current | Accepting new patients |
Locations
6501 Stanley Ave
Berwyn, IL 60402
Phone (708) 484-7400
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
- Adolescent and Children Mental Health Clinic/Center
- Berwyn, IL
- NPI 1629778550
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1598572800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1598572800000",
"number": "1083227995",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "5018 W 23RD ST",
"city": "CICERO",
"state": "IL",
"postal_code": "608042927",
"telephone_number": "334-718-9025"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "6501 STANLEY AVE",
"city": "BERWYN",
"state": "IL",
"postal_code": "604023123",
"telephone_number": "708-484-7400"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLEN",
"first_name": "JACLYN",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2020-08-28",
"last_updated": "2020-08-28",
"certification_date": "2020-08-28",
"status": "A"
},
"taxonomies": [
{
"code": "101YM0800X",
"taxonomy_group": "",
"desc": "Counselor, Mental Health",
"state": "IL",
"license": "180.008708",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Berwyn, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 28, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.