=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689936312
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASMINE ALLEGRA TUDY SAULS M.S., MFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2012
-----------------------------------------------------
Last Update Date | 06/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 649 BARRON BLVD
-----------------------------------------------------
City | GRAYSLAKE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60030-1327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-231-3840
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 649 BARRON BOULEVARD
-----------------------------------------------------
City | GRAYSLAKE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60030-1327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-231-3840
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 166000785
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC40231
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------