Basic Information
Provider Information | |||||||||
NPI: | 1275525412 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHICAGO DEPARTMENT OF PUBLIC HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CDPH | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 333 S STATE ST | ||||||||
Address2: | #200 CHICAGO DEPARTMENT OF PUBLIC HEALTH | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606043900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3127479443 | ||||||||
FaxNumber: | 3127479447 | ||||||||
Practice Location | |||||||||
Address1: | 4314 S COTTAGE GROVE AVE | ||||||||
Address2: | GREATER GRAND MENTAL HEALTH CENTER | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606533514 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3127470036 | ||||||||
FaxNumber: | 3127472208 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/15/2005 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JACKSON | ||||||||
AuthorizedOfficialFirstName: | SARAI | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF REVENUE | ||||||||
AuthorizedOfficialTelephone: | 3127479443 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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.