Provider Demographics
NPI:1710584917
Name:LANE, JESSICA LEE (MS-MFT, ALMFT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:LANE
Suffix:
Gender:F
Credentials:MS-MFT, ALMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8616 SCOTT LN
Mailing Address - Street 2:
Mailing Address - City:MACHESNEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61115-2586
Mailing Address - Country:US
Mailing Address - Phone:815-914-0063
Mailing Address - Fax:
Practice Address - Street 1:5290 WILLIAMS DR
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-9222
Practice Address - Country:US
Practice Address - Phone:815-324-0324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-01
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208.00854106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist