=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992100747
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | C G JUNG CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2014
-----------------------------------------------------
Last Update Date | 10/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 817 DEMPSTER ST
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-4303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-475-4848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 817 DEMPSTER ST
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-4303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-475-4848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOARD MEMBER
-----------------------------------------------------
Name | MS. DIANE M MILLER
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 847-951-5388
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------