Healthcare Provider Details

I. General information

NPI: 1174574016
Provider Name (Legal Business Name): JAMAL PLACE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1335 S CALIFORNIA AVE
CHICAGO IL
60608-1611
US

IV. Provider business mailing address

1335 S. CALIFORNIA AVE
CHICAGO IL
60608-1611
US

V. Phone/Fax

Practice location:
  • Phone: 773-277-6631
  • Fax: 773-277-7049
Mailing address:
  • Phone: 773-277-6631
  • Fax: 773-277-7049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number246705-05
License Number StateIL

VIII. Authorized Official

Name: BRIAN BARCLAY
Title or Position: TLP DIRECTOR
Credential: MSW
Phone: 773-722-5270