MEDICARE: MS. JENNIFER L LIRA LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker		IL

General Provider Information

NPI Number	:	1104960442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER L LIRA LCSW

Provider Business Mailing Address
First Line	:	2400 N LAKEVIEW AVE APT 408
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-2732
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3040 N WILTON AVE
Second Line	:	2ND FLOOR
City	:	CHICAGO
State	:	IL
Zip	:	60657-4424
Country	:	US
Telephone Number	:	773-296-5677
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/19/2007
Last Update Date	:	07/08/2007

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