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General NPI Number Information
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NPI Number | 1932110020
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Entity Type | Individual
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Provider Name | MARK GEORGE JIARAS PSY.D.
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Gender | Male
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Dates
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Enumeration Date | 08/11/2006
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Last Update Date | 10/19/2020
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Provider Practice Location Address
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Address Line | 825 GREEN BAY RD STE 210
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City | WILMETTE
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State | IL
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Zip | 60091-2500
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Country | US
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Telephone | 847-630-3900
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Fax |
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Provider Business Mailing Address
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Address Line | 1117 LINCOLN ST
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City | GLENVIEW
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State | IL
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Zip | 60025-2873
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Country | US
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Telephone | 773-794-0717
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Fax | 773-794-0787
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071-006111
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License Number State | IL
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