MEDICARE: JONATHAN ANDERSON

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	101YP2500X	Professional Counselor	178009461	IL

General Provider Information

NPI Number	:	1396122362
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN ANDERSON

Provider Business Mailing Address
First Line	:	3436 N KENNICOTT AVE
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004-7814
Country	:	US
Telephone Number	:	847-952-7460
Fax Number	:	847-222-1754

Provider Business Practice Location Address
First Line	:	1655 N ARLINGTON HEIGHTS RD STE 301W
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004-3900
Country	:	US
Telephone Number	:	224-735-3935
Fax Number	:

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

Provider Enumeration Date	:	04/29/2015
Last Update Date	:	09/19/2018

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