=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710432042
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JKOROTKO COUNSELING AND ART THERAPY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2016
-----------------------------------------------------
Last Update Date | 08/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2858 W DIVERSEY AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-1871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-683-2781
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2858 W DIVERSEY AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-1871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-683-2781
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST AND FOUNDER
-----------------------------------------------------
Name | JENIFER CORINNE KOROTKO
-----------------------------------------------------
Credential | ATR, LCPC
-----------------------------------------------------
Telephone | 773-683-2781
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180008029
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------