MEDICARE: JOSE DE JESUS INIGUEZ PHD, LCPC

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	180.011950	IL

General Provider Information

NPI Number	:	1891266391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSE DE JESUS INIGUEZ PHD, LCPC

Provider Business Mailing Address
First Line	:	4043 S RICHMOND ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632-1831
Country	:	US
Telephone Number	:	773-491-9815
Fax Number	:

Provider Business Practice Location Address
First Line	:	2755 W ARMITAGE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-4244
Country	:	US
Telephone Number	:	773-252-3100
Fax Number	:

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

Provider Enumeration Date	:	12/09/2018
Last Update Date	:	12/09/2018

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