Healthcare Provider Details

I. General information

NPI: 1619551504
Provider Name (Legal Business Name): JAKE REX ERICKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2021
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 W BELMONT AVE
CHICAGO IL
60657-4408
US

IV. Provider business mailing address

128 GROVE ST
IOWA CITY IA
52246-2300
US

V. Phone/Fax

Practice location:
  • Phone: 312-530-0323
  • Fax:
Mailing address:
  • Phone: 208-390-8016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036.179922
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD-53310
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: