MEDICARE: MR. JACK F. SHAUGER 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	149008239	IL

General Provider Information

NPI Number	:	1275812034
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACK F. SHAUGER LCSW

Provider Business Mailing Address
First Line	:	5520 N GLENWOOD AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-1217
Country	:	US
Telephone Number	:	773-746-3110
Fax Number	:

Provider Business Practice Location Address
First Line	:	3656 N HALSTED ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-5974
Country	:	US
Telephone Number	:	773-746-3110
Fax Number	:

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

Provider Enumeration Date	:	08/11/2011
Last Update Date	:	08/12/2011

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