Provider Demographics
NPI:1265157903
Name:POISSON, JANAE ELIZABETH
Entity type:Individual
Prefix:
First Name:JANAE
Middle Name:ELIZABETH
Last Name:POISSON
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 1:1325 SYCAMORE RD
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-2483
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4331 LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-2404
Practice Address - Country:US
Practice Address - Phone:708-748-1951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-05
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL17004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health