=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013707819
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TATIANA JONES-MOORE LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2025
-----------------------------------------------------
Last Update Date | 06/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 404 N HERSHEY RD STE C
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61704-3560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-381-6538
-----------------------------------------------------
Fax | 309-590-5990
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55 E JACKSON BLVD STE 1500
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60604-4184
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-663-1300
-----------------------------------------------------
Fax | 312-663-0504
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 150107206
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149029569
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------