Active NPI
Persell Jefferson
- Clinical Psychologist
- Chicago, IL
National Provider Identifier
1992580666
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 1110-1110
- Practice address
- 11337 S Wallace St
Chicago, IL 60628-4729 - Phone
- (773) 698-3088
- NPI assigned
- Aug 30, 2023
- Sex
- Male
- Sole proprietor
- Yes
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 |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 1110-1110 | IL | Primary |
Addresses
Primary practice location
11337 S Wallace St
Chicago, IL 60628-4729
Mailing address
11337 S Wallace St
Chicago, IL 60628-4729
Phone (773) 698-3088
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 |
|---|---|---|---|
| 1110-1110 | IL | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1693353600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1693353600000",
"number": "1992580666",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "11337 S WALLACE ST",
"city": "CHICAGO",
"state": "IL",
"postal_code": "606284729",
"telephone_number": "773-698-3088"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "11337 S WALLACE ST",
"city": "CHICAGO",
"state": "IL",
"postal_code": "606284729",
"telephone_number": "773-698-3088"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JEFFERSON",
"first_name": "PERSELL",
"name_prefix": "Mr.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2023-08-30",
"last_updated": "2023-08-30",
"certification_date": "2021-09-09",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "IL",
"license": "1110-1110",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Chicago, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 30, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.