MEDICARE: IBI JESSICA JEREMIAH LCSW

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	149017398	IL

General Provider Information

NPI Number	:	1477097962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IBI JESSICA JEREMIAH LCSW

Provider Business Mailing Address
First Line	:	8029 S. PAXTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-1159
Country	:	US
Telephone Number	:	414-530-3850
Fax Number	:

Provider Business Practice Location Address
First Line	:	8029 S PAXTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-1159
Country	:	US
Telephone Number	:	414-530-3850
Fax Number	:

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

Provider Enumeration Date	:	12/19/2016
Last Update Date	:	12/19/2016

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