MEDICARE: JARED RYAN ROBL 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	149015806	IL

General Provider Information

NPI Number	:	1184064958
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JARED RYAN ROBL LCSW

Provider Business Mailing Address
First Line	:	2537 N HAMLIN AVE
Second Line	:	APT #1
City	:	CHICAGO
State	:	IL
Zip	:	60647-1007
Country	:	US
Telephone Number	:	316-648-1537
Fax Number	:

Provider Business Practice Location Address
First Line	:	2537 N HAMLIN AVE
Second Line	:	APT #1
City	:	CHICAGO
State	:	IL
Zip	:	60647-1007
Country	:	US
Telephone Number	:	316-648-1537
Fax Number	:

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

Provider Enumeration Date	:	06/26/2013
Last Update Date	:	06/26/2013

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