Healthcare Provider Details

I. General information

NPI: 1689368789
Provider Name (Legal Business Name): JEROME NERIO NONE MISSAY SOKU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 06/05/2023
Certification Date: 06/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 E CHESTNUT ST FL 3
CHICAGO IL
60611-2014
US

IV. Provider business mailing address

1615 E 31ST ST
LA GRANGE PARK IL
60526-1319
US

V. Phone/Fax

Practice location:
  • Phone: 312-787-8425
  • Fax:
Mailing address:
  • Phone: 708-800-7916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: