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General NPI Number Information
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NPI Number | 1972035418
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Entity Type | Organization
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Legal Business Name | JANE E. SAMUELSON, PHD, LTD
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Dates
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Enumeration Date | 04/03/2017
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Last Update Date | 04/03/2017
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Provider Practice Location Address
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Address Line | 111 NORTH WABASH SUITE 1704
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City | CHICAGO
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State | IL
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Zip | 60602-1900
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Country | US
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Telephone | 708-524-1267
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Fax |
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Provider Business Mailing Address
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Address Line | 111 NORTH WABASH SUITE 1704
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City | CHICAGO
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State | IL
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Zip | 60602-1900
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Country | US
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Telephone | 708-524-1267
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Fax |
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | DR. JANE E. SAMUELSON
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Credential | PHD
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Telephone | 708-524-1267
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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 | 071-003172
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License Number State | IL
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