MEDICARE: GRANT ADVOCATE & COUNSELING SVC OF IL

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	251S00000X	Community/Behavioral Health Agency		IL

General Provider Information

NPI Number	:	1285819342
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRANT ADVOCATE & COUNSELING SVC OF IL

Provider Business Mailing Address
First Line	:	PO BOX 803031
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60680-3031
Country	:	US
Telephone Number	:	773-629-0524
Fax Number	:

Provider Business Practice Location Address
First Line	:	1649 E 50TH ST
Second Line	:	#7E
City	:	CHICAGO
State	:	IL
Zip	:	60615-3128
Country	:	US
Telephone Number	:	773-629-0524
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN OWNER
Name	:	DR. JERISA C. JOHNSON
Credential	:	D.O.
Telephone Number	:	773-629-0524

Provider Enumeration Date	:	01/08/2008
Last Update Date	:	01/08/2008

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