MEDICARE: CHICAGO DEPARTMENT OF PUBLIC HEALTH

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)		IL

General Provider Information

NPI Number	:	1184616328
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO DEPARTMENT OF PUBLIC HEALTH

Provider Business Mailing Address
First Line	:	CHICAGO DEPARTMENT OF PUBLIC HEALTH
Second Line	:	333 S STATE STREET REVENUE #200
City	:	CHICAGO
State	:	IL
Zip	:	60604
Country	:	US
Telephone Number	:	312-747-9443
Fax Number	:	312-747-9447

Provider Business Practice Location Address
First Line	:	BACK OF THE YARDS MENTAL HEALTH CENTER
Second Line	:	4313 S ASHLAND
City	:	CHICAGO
State	:	IL
Zip	:	40609
Country	:	US
Telephone Number	:	312-747-3560
Fax Number	:	312-747-8974

Authorized Official
Title or Position	:	DIRECTOR OF REVENUE
Name	:	MRS. SARAI M JACKSON
Credential	:
Telephone Number	:	312-747-9443

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	08/22/2020

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