MEDICARE: THE CENTER FOR JEWISH ADOLESCENT THERAPY

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	1041C0700X	Clinical Social Worker	149015020	IL

General Provider Information

NPI Number	:	1326409111
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE CENTER FOR JEWISH ADOLESCENT THERAPY

Provider Business Mailing Address
First Line	:	3557 W PETERSON AVE
Second Line	:	SUITE 128
City	:	CHICAGO
State	:	IL
Zip	:	60659-3218
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3557 W PETERSON AVE
Second Line	:	SUITE 128
City	:	CHICAGO
State	:	IL
Zip	:	60659-3218
Country	:	US
Telephone Number	:	917-541-2740
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	LORI J NEWMAN
Credential	:	BA CPC
Telephone Number	:	708-560-6653

Provider Enumeration Date	:	03/08/2016
Last Update Date	:	03/08/2016

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