MEDICARE: MR. JACK D NEIDITCH L.C.S.W.

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	149-009897	IL

General Provider Information

NPI Number	:	1861711541
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACK D NEIDITCH L.C.S.W.

Provider Business Mailing Address
First Line	:	700 W BITTERSWEET PL
Second Line	:	UNIT 606
City	:	CHICAGO
State	:	IL
Zip	:	60613-2354
Country	:	US
Telephone Number	:	773-525-9945
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	:	773-525-9945
Fax Number	:

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

Provider Enumeration Date	:	05/20/2010
Last Update Date	:	05/20/2010

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