MEDICARE: JACK CORBETT

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	106S00000X	Behavior Technician		IL

General Provider Information

NPI Number	:	1205799657
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK CORBETT

Provider Business Mailing Address
First Line	:	3007 W LAWRENCE AVE APT 2W
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-7375
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2700 W PETERSON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-3920
Country	:	US
Telephone Number	:	224-491-4136
Fax Number	:

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

Provider Enumeration Date	:	12/03/2025
Last Update Date	:	12/03/2025

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Directions to “ JACK CORBETT ” Practice Location

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