Healthcare Provider Details

I. General information

NPI: 1972815488
Provider Name (Legal Business Name): MARIE RICHARD-JACKSON MSW,QMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2010
Last Update Date: 07/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 S STATE ST
CHICAGO IL
60604-3900
US

IV. Provider business mailing address

333 S STATE ST
CHICAGO IL
60604-3900
US

V. Phone/Fax

Practice location:
  • Phone: 312-744-1906
  • Fax: 312-744-5568
Mailing address:
  • Phone: 312-744-1906
  • Fax: 312-744-5568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: