MEDICARE: ALAN M JAFFE PSYD

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	J10001352304	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01672615	OTHER	IL	BLUE SHIELD PROVIDER NUMB

General Provider Information

NPI Number	:	1437187689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALAN M JAFFE PSYD

Provider Business Mailing Address
First Line	:	30 N MICHIGAN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60602-3727
Country	:	US
Telephone Number	:	312-346-2640
Fax Number	:

Provider Business Practice Location Address
First Line	:	30 N MICHIGAN AVE
Second Line	:	SUITE 1206
City	:	CHICAGO
State	:	IL
Zip	:	60602-3402
Country	:	US
Telephone Number	:	312-346-2640
Fax Number	:

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

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	07/08/2007

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