Basic Information
| Provider Information | |||||||||
| NPI: | 1255333639 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHICAGO DEPARTMENT OF PUBLIC HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CDPH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 S STATE ST | ||||||||
| Address2: | REVENUE #200 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606043900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127479443 | ||||||||
| FaxNumber: | 3127479447 | ||||||||
| Practice Location | |||||||||
| Address1: | 1140 W 79TH ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606203029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127470881 | ||||||||
| FaxNumber: | 3127477796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | SARAI | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REVENUE | ||||||||
| AuthorizedOfficialTelephone: | 3127479443 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.