Healthcare Provider Details

I. General information

NPI: 1598757726
Provider Name (Legal Business Name): CHICAGO DEPARTMENT OF PUBLIC HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROSELAND MENTAL HEALTH CENTER 28 E 112TH PLACE
CHICAGO IL
60628
US

IV. Provider business mailing address

333 SOUTH STATE STREET REVENUE #200
CHICAGO IL
60604
US

V. Phone/Fax

Practice location:
  • Phone: 312-747-7320
  • Fax: 312-747-9143
Mailing address:
  • Phone: 312-747-9443
  • Fax: 312-747-9447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateIL

VIII. Authorized Official

Name: MRS. SARAI M JACKSON
Title or Position: DIRECTOR OF REVENUE
Credential:
Phone: 312-747-9443