MEDICARE: JACLYN KAMRADT PHD, P.C.

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	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1396450706
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACLYN KAMRADT PHD, P.C.

Provider Business Mailing Address
First Line	:	11545 ASHBURY CT
Second Line	:
City	:	MOKENA
State	:	IL
Zip	:	60448-9490
Country	:	US
Telephone Number	:	708-373-9440
Fax Number	:

Provider Business Practice Location Address
First Line	:	2081 CALISTOGA DR STE 2N
Second Line	:
City	:	NEW LENOX
State	:	IL
Zip	:	60451-4833
Country	:	US
Telephone Number	:	708-373-9440
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL PSYCHOLOGIST
Name	:	DR. JACLYN KAMRADT
Credential	:	PHD
Telephone Number	:	708-373-9440

Provider Enumeration Date	:	01/19/2023
Last Update Date	:	01/19/2023

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