=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295306322
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN HANDRUP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2021
-----------------------------------------------------
Last Update Date | 07/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 E DEERPATH
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60045-1952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-796-6400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1061 W 16TH ST APT 411
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60608-2863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-498-9460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 150105239
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------