=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588738652
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACK CHARLES SANDERS MSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6650 NORTH NORTHWEST HWY SUITE 201
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60631-1307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-467-1154
-----------------------------------------------------
Fax | 773-262-7237
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2229 WEST FARWELL AVE 1 WEST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60645-4809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-467-1154
-----------------------------------------------------
Fax | 773-262-7237
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------