MEDICARE: MRS. JENNIS STOPKA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	178003545	IL
2	101YP2500X	Professional Counselor	180.008273	IL

General Provider Information

NPI Number	:	1104028166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIS STOPKA

Provider Business Mailing Address
First Line	:	2637 W RICE ST
Second Line	:	#2
City	:	CHICAGO
State	:	IL
Zip	:	60622-4541
Country	:	US
Telephone Number	:	773-517-6520
Fax Number	:

Provider Business Practice Location Address
First Line	:	2637 W RICE ST
Second Line	:	#2
City	:	CHICAGO
State	:	IL
Zip	:	60622-4541
Country	:	US
Telephone Number	:	773-517-6520
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2007
Last Update Date	:	11/02/2012

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