=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275812034
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACK F. SHAUGER LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2011
-----------------------------------------------------
Last Update Date | 08/12/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3656 N HALSTED ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60613-5974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-746-3110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5520 N GLENWOOD AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-1217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-746-3110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149008239
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------