Healthcare Provider Details

I. General information

NPI: 1619733458
Provider Name (Legal Business Name): JADE MARIE AUSTIN MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2024
Last Update Date: 02/27/2024
Certification Date: 02/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 DAVIS ST
EVANSTON IL
60201-4619
US

IV. Provider business mailing address

940 W CULLOM AVE
CHICAGO IL
60613-1619
US

V. Phone/Fax

Practice location:
  • Phone: 312-815-9660
  • Fax:
Mailing address:
  • Phone: 773-525-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: