Healthcare Provider Details

I. General information

NPI: 1235879990
Provider Name (Legal Business Name): JOHN B WICKHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2022
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3948 N SHERIDAN RD STE 100
CHICAGO IL
60613-2935
US

IV. Provider business mailing address

1025 W SUNNYSIDE AVE STE 100
CHICAGO IL
60640-5684
US

V. Phone/Fax

Practice location:
  • Phone: 773-388-1600
  • Fax: 773-388-8936
Mailing address:
  • Phone: 773-388-1600
  • Fax: 773-388-8936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.024244
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: