Healthcare Provider Details

I. General information

NPI: 1659830966
Provider Name (Legal Business Name): JEAN TAJ VILUS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2019
Last Update Date: 05/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E HURON ST
CHICAGO IL
60611-2908
US

IV. Provider business mailing address

407 DUDLEY ST UNIT 7
ROXBURY MA
02119-3392
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-2000
  • Fax:
Mailing address:
  • Phone: 224-587-0642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number125.073889
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: