MEDICARE: JANE E PELLER

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		IL

General Provider Information

NPI Number	:	1427128214
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANE E PELLER

Provider Business Mailing Address
First Line	:	2320 THAYER ST
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60201-1412
Country	:	US
Telephone Number	:	847-424-9344
Fax Number	:	847-475-2691

Provider Business Practice Location Address
First Line	:	1620 W THOME AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-1212
Country	:	US
Telephone Number	:	847-424-2934
Fax Number	:	847-475-2691

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

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	07/08/2007

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Directions to “ JANE E PELLER ” Practice Location

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