Healthcare Provider Details

I. General information

NPI: 1104163351
Provider Name (Legal Business Name): JESUS QUIJADA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2013
Last Update Date: 01/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 HEBRON AVE
ZION IL
60099-2260
US

IV. Provider business mailing address

3010 GRAND AVE
WAUKEGAN IL
60085-2321
US

V. Phone/Fax

Practice location:
  • Phone: 847-746-0701
  • Fax:
Mailing address:
  • Phone: 847-377-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: