Healthcare Provider Details

I. General information

NPI: 1225855687
Provider Name (Legal Business Name): JAMIE MARASCO GEBHARDT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2024
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6430 N CENTRAL AVE
CHICAGO IL
60646-2925
US

IV. Provider business mailing address

830 N MILWAUKEE AVE APT 406
CHICAGO IL
60642-4299
US

V. Phone/Fax

Practice location:
  • Phone: 312-806-7937
  • Fax:
Mailing address:
  • Phone: 414-801-1255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-378357
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: