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NPI Code Detail

MEDICARE: MR. JEROME J KLINKNER LCSW

MEDICARE: MR. JEROME J KLINKNER 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
11041C0700XClinical Social Worker149-007838IL

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1K20147OTHERILMEDICARE, PROVIDER ID, PROVIDER IN A GROUP

General Provider Information

NPI Number : 1124273149
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. JEROME J KLINKNER LCSW
Provider Business Mailing Address
First Line : 305 RIDGE AVE APT 1
Second Line :
City : EVANSTON
State : IL
Zip : 60202-6416
Country : US
Telephone Number : 847-866-9067
Fax Number :
Provider Business Practice Location Address
First Line : 6450 N RIDGE BLVD
Second Line :
City : CHICAGO
State : IL
Zip : 60626-4804
Country : US
Telephone Number : 773-743-8700
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/18/2008
Last Update Date : 10/02/2019

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