=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336502434
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK JIARAS LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2016
-----------------------------------------------------
Last Update Date | 04/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4200 W PETERSON AVE SUITE 105
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60646-6074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-630-3900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4200 W PETERSON AVE SUITE 105
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60646-6074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-630-3900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARK JIARAS
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 847-630-3900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 071-006111
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------