Provider Demographics
NPI:1679807614
Name:LEE, MARY JACKSON (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JACKSON
Last Name:LEE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 894
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-0894
Mailing Address - Country:US
Mailing Address - Phone:630-415-8980
Mailing Address - Fax:630-653-7877
Practice Address - Street 1:615 W FRONT ST
Practice Address - Street 2:SUITE 201
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-4935
Practice Address - Country:US
Practice Address - Phone:630-415-8980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490079561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical