Healthcare Provider Details

I. General information

NPI: 1043749310
Provider Name (Legal Business Name): JAQ L ZUIDEMA LCSW, ASDCS, TIYT
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 W MONTROSE AVE # 790
CHICAGO IL
60641-2140
US

IV. Provider business mailing address

8263 S HARVARD AVE # 1015
TULSA OK
74137-1614
US

V. Phone/Fax

Practice location:
  • Phone: 918-558-0338
  • Fax:
Mailing address:
  • Phone: 918-558-0338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number21219
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.028001
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: