MEDICARE: MARCUS JACK

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	180014299	IL

General Provider Information

NPI Number	:	1306591342
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARCUS JACK

Provider Business Mailing Address
First Line	:	5640 STONE CT
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30087-2954
Country	:	US
Telephone Number	:	770-912-5225
Fax Number	:

Provider Business Practice Location Address
First Line	:	12400 S MICHIGAN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60628-7347
Country	:	US
Telephone Number	:	770-912-5225
Fax Number	:

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

Provider Enumeration Date	:	02/17/2022
Last Update Date	:	02/17/2022

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Directions to “ MARCUS JACK ” Practice Location

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