Healthcare Provider Details

I. General information

NPI: 1104747187
Provider Name (Legal Business Name): JASON KOUGAN LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

414 CLINTON PL STE 106
RIVER FOREST IL
60305-2248
US

IV. Provider business mailing address

414 CLINTON PL STE 106
RIVER FOREST IL
60305-2248
US

V. Phone/Fax

Practice location:
  • Phone: 708-866-6766
  • Fax: 708-526-8311
Mailing address:
  • Phone: 708-866-6766
  • Fax: 708-526-8311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.129650
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: