Healthcare Provider Details

I. General information

NPI: 1689864126
Provider Name (Legal Business Name): RAPHAEL A JUSS EDD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2007
Last Update Date: 07/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N LAKE SHORE DRIVE SUITE 13D
CHICAGO IL
60610-2193
US

IV. Provider business mailing address

1300 N LAKE SHORE DRIVE SUITE 13D
CHICAGO IL
60610-2193
US

V. Phone/Fax

Practice location:
  • Phone: 312-642-7785
  • Fax:
Mailing address:
  • Phone: 312-642-7785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC 365
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number10580
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number969747
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1233025
License Number State
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMT 145
License Number StateTN
# 6
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: